Lifestyle Modification and Atrial Fibrillation: Critical Care for Successful Ablation

Prognostic Impact of Sinus Rhythm in Atrial Fibrillation Patients: Separating Rhythm Outcomes From Randomized Strategy Findings From the CABANA Trial

BACKGROUND

Clinically detected atrial fibrillation (AF) is associated with a significant increase in mortality and other adverse cardiovascular events. Since the advent of effective methods for AF rhythm control, investigators have attempted to determine how much these adverse prognostic AF effects could be mitigated by the restoration of sinus rhythm (SR) and whether the method used mattered.

METHODS

The CABANA trial (Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation) randomized 2204 AF patients to ablation versus drug therapy, of which 1240 patients were monitored in follow-up using the CABANA ECG rhythm monitoring system. To assess the prognostic benefits of SR, we performed a prespecified analysis using Cox survival modeling with heart rhythm as a time-dependent variable and randomized treatment group as a stratification factor.

RESULTS

In the 1240 patient study cohort, 883 (71.2%) had documented AF at some point during their postblanking follow-up. Among the 883 patients, 671 (76.0%) experienced AF within the first year of postblanking follow-up, and 212 (24.0%) experienced their first AF after ≥1 year of postblanking follow-up. The primary CABANA end point (death, disabling stroke, serious bleeding, or cardiac arrest) occurred in 95 (10.8%) of the 883 patients with documented AF and in 29 (8.1%) of the 357 patients with no AF recorded during follow-up. In multivariable time-dependent analysis, the presence of SR (compared with non-SR) was associated with a significantly reduced risk of the primary end point (adjusted hazard ratio, 0.57 [95% CI, 0.38-0.85]; P=0.006; independent of treatment strategy [ablation versus drugs]). Corresponding results for all-cause mortality were adjusted hazard ratio of 0.59 [95% CI, 0.35-1.01]; P=0.053).

CONCLUSIONS

In patients in the CABANA trial with detailed long-term rhythm follow-up, increased time in SR was associated with a clinically consequential decrease in mortality and other adverse prognostic events. The predictive value of SR was independent of the therapeutic approach responsible for reducing the burden of detectable AF.

REGISTRATION

URL: https://clinicaltrials.gov; Unique Identifier: NCT00911508.

Social determinants of health and recurrence of atrial fibrillation after catheter ablation: a Danish nationwide cohort study

AIMS

To examine the associations between three social determinants of health (SDOH) and recurrence of AF after ablation.

METHODS AND RESULTS

We selected patients who underwent a first ablation after an incident hospital diagnosis of AF between 2005 and 2018 from the entire Danish population. Educational attainment, family income, and whether the patient was living alone were assessed at the time of ablation. We used cause-specific proportional hazard models to estimate hazard ratios (HR) with 95% confidence interval (CI) adjusted for age and sex. In secondary analyses, we adjusted for comorbidities, antiarrhythmic medication, and prior electrical cardioversion.We selected 9728 patients (mean age 61 years, 70% men), and 5881 patients had AF recurrence over an average of 1.37 years after ablation (recurrence rate 325.7 (95% CI 317.6-334.2) per 1000 person-years). Lower education (HR 1.09 [1.02-1.17] and 1.07 [1.01-1.14] for lower and medium vs. higher), lower income [HR 1.14 (1.06-1.22) and 1.09 (1.03-1.17) for lower and medium vs. higher], and living alone [HR 1.07 (1.00-1.13)] were associated with increased rates of recurrence of AF. We found no evidence of interaction between sex or prior HF with SDOH. The association between family income and AF recurrence was stronger among patients < 65 years compared with those aged ≥ 65 years. The associations between SDOH and AF recurrence did not persist in the multivariable model.

CONCLUSION

AF was more likely to recur among patients with lower educational attainment, lower family income, or those living alone. Multidisciplinary efforts are needed to reduce socioeconomic inequity in the effect of ablation.

In-hospital complications associated with pulmonary vein isolation with adjunctive lesions: the NCDR AFib Ablation Registry

AIMS

No prior study has been adequately powered to evaluate real-world safety outcomes in those receiving adjunctive ablation lesions beyond pulmonary vein isolation (PVI). We sought to evaluate characteristics and in-hospital complications among patients undergoing PVI with and without adjunctive lesions.

METHODS AND RESULTS

Patients in the National Cardiovascular Data Registry AFib Ablation Registry undergoing first-time atrial fibrillation (AF) ablation between 2016 and 2020 were identified and stratified into paroxysmal (PAF) and persistent AF, and separated into PVI only, PVI + cavotricuspid isthmus (CTI) ablation, and PVI + adjunctive (superior vena cava isolation, coronary sinus, vein of Marshall, atypical atrial flutter lines, other). Adjusted odds of adverse events were calculated using multivariable logistic regression. A total of 50 937 patients [PAF: 30 551 (60%), persistent AF: 20 386 (40%)] were included. Among those with PAF, there were no differences in the adjusted odds of complications between PVI + CTI or PVI + adjunctive when compared with PVI only. Among persistent AF, PVI + adjunctive was associated with a higher risk of any complication [3.0 vs. 4.5%, odds ratio (OR) 1.30, 95% confidence interval (CI) 1.07-1.58] and major complication (0.8 vs. 1.4%, OR 1.56, 95% CI 1.10-2.21), while no differences were observed in PVI + CTI compared with PVI only. Overall, there was high heterogeneity in adjunctive lesion type, and those receiving adjunctive lesions had a higher comorbidity burden.

CONCLUSION

Additional CTI ablation was common without an increased risk of complications. Adjunctive lesions other than CTI are commonly performed in those with more comorbidities and were associated with an increased risk of complications in persistent AF, although the current analysis is limited by high heterogeneity in adjunctive lesion set type.

[Alternative treatment strategies for atrial fibrillation : Benefits from yoga?]

Atrial fibrillation, the most common sustained cardiac arrhythmia, is associated with significant morbidity, mortality, and healthcare utilization. Since the procedures used to treat atrial fibrillation have a number of limitations and risks, there is a growing interest in alternative treatment strategies for patients with atrial fibrillation. One such option is yoga. To date, only a few studies are available on its effect on atrial fibrillation. However, these suggest that yoga may indeed be able to reduce the frequency of the arrhythmia and its progression. The risk factors for atrial fibrillation and quality of life in affected patients are also positively affected. As adverse effects and complications are extremely rare with competent guidance, yoga may already be recommended now. However, further clinical studies are needed to provide recommendations that meet evidence-based criteria.

Genetic Predisposition to a Higher Whole Body Water Mass May Increase the Risk of Atrial Fibrillation: A Mendelian Randomization Study

BACKGROUND

Observational studies have found an association between increased whole body water mass (BWM) and atrial fibrillation (AF). However, the causality has yet to be confirmed. To provide feasible protective measures on disease development, we performed Mendelian randomization (MR) design to estimate the potential causal relationship between increased BWM and AF.

METHODS

We implemented a two-sample MR study to assess whether increased BWM causally influences AF incidence. For exposure, 61 well-powered genetic instruments extracted from UK Biobank (N = 331,315) were used as the proxies of BWM. Summary genetic data of AF were obtained from FinnGen (Ncase = 22,068; Ncontrol = 116,926). Inverse-variance weighted (IVW), MR-Egger and weighted median methods were selected to infer causality, complemented with a series of sensitivity analyses. MR-Pleiotropy Residual Sum and Outlier (MR-PRESSO) and Radial MR were employed to identify outliers. Furthermore, risk factor analyses were performed to investigate the potential mechanisms between increased BWM and AF.

RESULTS

Genetic predisposition to increased BWM was demonstrated to be significantly associated with AF in the IVW model (OR = 2.23; 95% CI = 1.47-3.09; p = 1.60 × 10^-7), and the result was consistent in other MR approaches. There was no heterogeneity or pleiotropy detected in sensitivity analysis. MR-PRESSO identified no outliers with potential pleiotropy after excluding outliers by Radial MR. Furthermore, our risk factor analyses supported a positive causal effect of genetic predicted increased BWM on edematous diseases.

CONCLUSIONS

MR estimates showed that a higher BWM could increase the risk of AF. Pathological edema is an important intermediate link mediating this causal relationship.

Reablation in Atrial Fibrillation Recurrence and Pulmonary Vein Reconnection: Cryoballoon versus Radiofrequency as Index Ablation Procedures

Pulmonary vein (PV) isolation is a well-established rhythm control therapy in atrial fibrillation (AF). Currently, there is no consensus on which ablation technique to use for the first procedure, cryoballoon (CB) or radiofrequency (RF). A retrospective cohort study was conducted on 1055 patients who underwent a first ablation, to assess both techniques based on the need for reablation. Patients with CB (n = 557) and RF (n = 498) ablations were clinically characterized and the need for reablation during a 30-month follow-up was used as the primary endpoint. Independent variables were analyzed to identify potential predictors. The need for reablation was significantly lower in the CB group than in the RF group (hazard ratio = 0.45 and 95% confident interval = 0.32−0.61; p < 0.001); in both paroxysmal and persistent AF, using a full-adjusted regression Cox model by age, sex, smoking, hypertension, diabetes mellitus, dyslipidemia, severe obstructive sleep apnea, dilated left atrium, persistent AF and early recurrence. RF ablation, dilated left atrium, persistent AF and early recurrence were identified as independent predictors of reablation. In addition, the CB-redo subgroup had a lower PV reconnection than the RF-redo subgroup. In conclusion, CB ablation suggests a reduction in the need for reablation and lower PV reconnection during the follow-up than RF ablation.