Device-detected atrial sensing amplitudes as a marker of increased risk for new onset and progression of atrial high-rate episodes

BACKGROUND

Atrial high-rate episodes (AHREs) are frequent in patients with cardiac implantable electronic devices. A decrease in device-detected P-wave amplitude may be an indicator of periods of increased risk of AHRE.

OBJECTIVE

The objective of this study was to assess the association between P-wave amplitude and AHRE incidence.

METHODS

Remote monitoring data from 2579 patients with no history of atrial fibrillation (23% pacemakers and 77% implantable cardioverter-defibrillators, of which 40% provided cardiac resynchronization therapy) were used to calculate the mean P-wave amplitude during 1 month after implantation. The association with AHRE incidence according to 4 strata of daily burden duration (≥15 minutes, ≥6 hours, ≥24 hours, ≥7 days) was investigated by adjusting the hazard ratio with the CHA2DS2-VASc score.

RESULTS

The adjusted hazard ratio for 1-mV lower mean P-wave amplitude during the first month increased from 1.10 (95% confidence interval [CI], 1.05-1.15; P < .001) to 1.18 (CI, 1.09-1.28; P < .001) with AHRE duration strata from ≥15 minutes to ≥7 days independent of the CHA2DS2-VASc score. Of 871 patients with AHREs, those with 1-month P-wave amplitude <2.45 mV had an adjusted hazard ratio of 1.51 (CI, 1.19-1.91; P = .001) for progression of AHREs from ≥15 minutes to ≥7 days compared with those with 1-month P-wave amplitude ≥2.45 mV. Device-detected P-wave amplitudes decreased linearly during the 1 year before the first AHRE by 7.3% (CI, 5.1%-9.5%; P < .001 vs patients without AHRE).

CONCLUSION

Device-detected P-wave amplitudes <2.45 mV were associated with an increased risk of AHRE onset and progression to persistent forms of AHRE independent of the patient's risk profile.

Sex Differences in Epidemiology, Morphology, Mechanisms, and Treatment of Mitral Valve Regurgitation

Sex-related disparities have been recognized in incidence, pathological findings, pathophysiological mechanisms, and diagnostic pathways of non-rheumatic mitral regurgitation. Furthermore, access to treatments and outcomes for surgical and interventional therapies among women and men appears to be different. Despite this, current European and US guidelines have identified common diagnostic and therapeutic pathways that do not consider patient sex in decision-making. The aim of this review is to summarize the current evidence on sex-related differences in non-rheumatic mitral regurgitation, particularly regarding incidence, imaging modalities, surgical-derived evidence, and outcomes of transcatheter edge-to-edge repair, with the goal of informing clinicians about sex-specific challenges to consider when making treatment decisions for patients with mitral regurgitation.

Ventricular Arrhythmias and Implantable Cardioverter-Defibrillator Therapy in Women: A Propensity Score-Matched Analysis

BACKGROUND

Causes of sex differences in incidence of sustained ventricular arrhythmias (SVAs) are poorly understood.

OBJECTIVES

This study aims to investigate sex-specific risk of SVAs and device therapies by balancing sex groups in relation to several baseline characteristics with the propensity score (PS).

METHODS

We used a large remote monitoring dataset from implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy defibrillators (CRT-Ds). Study endpoints were time to the first appropriate SVA, time to the first device therapy for SVA, and time to the first ICD shock. Results were compared between females and a PS-matched male subgroup.

RESULTS

In a cohort of 2,532 patients with an ICD or CRT-D (median age, 70 years), 488 patients (19.3%) were women. After selecting 488 men PS-matched for 19 variables relative to baseline demographics, implant indications, principal comorbidities, and concomitant therapy, yet the SVA rate at the 2.1-year median follow-up was significantly lower in women than in man (adjusted HR: 0.65; 95% CI: 0.51-0.81; P < 0.001). Women also showed a reduced risk of any device therapy (HR: 0.59; 95% CI: 0.45-0.76; P < 0.001) and shocks (HR: 0.66; 95% CI: 0.47-0.94; P = 0.021). Differences in sex-specific SVA risk profile were not confirmed in CRT-D patients (HR: 0.78; 95% CI: 0.55-1.09; P = 0.14) nor in those with an ejection fraction <30% (HR: 0.80; 95% CI: 0.52-1.23; P = 0.31).

CONCLUSIONS

After matching demographics, indications, principal comorbidities, and concomitant therapy, women still exhibited a lower SVA risk profile than men, except in the subgroups of CRT-D or/and ejection fraction <30%.

Impact of myocardial injury on mortality and adverse events in hospitalized patients with influenza: a prospective cohort study

Background and aim

Myocardial injury (MINJ) defined as elevated high-sensitivity cardiac troponin level (hs-cTnT) above normal values is a well-recognized prognostic marker in different clinical conditions, nonetheless, its relevance in Influenza remains poorly defined. We aimed to analyse incidence, predictors, short and mid-term prognostic role of MINJ in hospitalized patients (pts) with Influenza.

Material and methods

During 2018–2019 Influenza epidemic, a prospective multicentre observational cohort study was conducted enrolling all hospitalized adult patients with laboratory confirmed Influenza infection. MINJ was prospectively assessed at admission and defined as hs-cTnT &gt;14 ng/L. Primary endpoint was all-cause death at 28-days. Secondary endpoints were all-cause death at 28-days or intensive care unit (ICU) admission/mechanical ventilation and all-cause death at follow up.

Results

145 consecutive pts were enrolled. MINJ was evident in 94 (65.5%) pts. At a 28-days follow up, 7 deaths (4.8%) occurred, all in patients with MINJ at admission (log rank p=0.048). MINJ showed a strong association with the occurrence of death, ICU admission or mechanical ventilation (OR 5.74, 95% CI 1.28–53.29; p=0.015). At a median follow-up of 32.7 months, 15 (10.3%) deaths occurred, all among patients with MINJ at index hospitalization leading to a significantly high mortality rate at follow-up among patients with MINJ (log-rank p=0.003).

Conclusions

Influenza related MINJ is common and identifies patients at higher likelihood of short-term adverse events and midterm mortality.

Funding Acknowledgement

Type of funding sources: None.

Comparative frequency and prognostic impact of myocardial injury in hospitalized patients with COVID-19 and Influenza

AIMS

Myocardial injury (MINJ) in Coronavirus disease 2019 (COVID-19) identifies individuals at high mortality risk but its clinical relevance is less well established for Influenza and no comparative analyses evaluating frequency and clinical implications of MINJ among hospitalized patients with Influenza or COVID-19 are available.

METHODS AND RESULTS

Hospitalized adults with laboratory confirmed Influenza A or B or COVID-19 underwent highly sensitive cardiac T Troponin (hs-cTnT) measurement at admission in four regional hospitals in Canton Ticino, Switzerland. MINJ was defined as hs-cTnT >14 ng/L. Clinical, laboratory and outcome data were retrospectively collected. The primary outcome was mortality up to 28 days. Cox regression models were used to assess correlations between admission diagnosis, MINJ, and mortality. Clinical correlates of MINJ in both viral diseases were also identified. MINJ occurred in 94 (65.5%) out of 145 patients hospitalized for Influenza and 216 (47.8%) out of 452 patients hospitalized for COVID-19. Advanced age and renal impairment were factors associated with MINJ in both diseases. At 28 days, 7 (4.8%) deaths occurred among Influenza and 76 deaths (16.8%) among COVID-19 patients with a hazard ratio (HR) of 3.69 [95% confidence interval (CI) 1.70-8.00]. Adjusted Cox regression models showed admission diagnosis of COVID-19 [HR 6.41 (95% CI 4.05-10.14)] and MINJ [HR 8.01 (95% CI 4.64-13.82)] to be associated with mortality.

CONCLUSIONS

Myocardial injury is frequent among both viral diseases and increases the risk of death in both COVID-19 and Influenza. The absolute risk of death is considerably higher in patients admitted for COVID-19 when compared with Influenza.

One-year mortality after implantable defibrillator implantation: do risk stratification models help improving clinical practice?

PURPOSE

The purpose of this study was to assess the available mortality risk stratification models for implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy defibrillator (CRT-D) patients.

METHODS

We conducted a review of mortality risk stratification models and tested their ability to improve prediction of 1-year survival after implant in a database of patients who received a remotely controlled ICD/CRT-D device during routine care and included in the independent Home Monitoring Expert Alliance registry.

RESULTS

We identified ten predicting models published in peer-reviewed journals between 2000 and 2021 (Parkash, PACE, MADIT, aCCI, CHA2DS2-VASc quartiles, CIDS, FADES, Sjoblom, AAACC, and MADIT-ICD non-arrhythmic mortality score) that could be tested in our database as based on common demographic, clinical, echocardiographic, electrocardiographic, and laboratory variables. Our cohort included 1,911 patients with left ventricular dysfunction (median age 71, 18.3% female) from sites not using any risk stratification score for systematic patient screening. Patients received an ICD (53.8%) or CRT-D (46.2%) between 2011 and 2017, after standard physician evaluation. There were 56 deaths within 1-year post-implant, with an all-cause mortality rate of 2.9% (95% confidence interval [CI], 2.3-3.8%). Four predicting models (Parkash, MADIT, AAACC, and MADIT-ICD non-arrhythmic mortality score) were significantly associated with increased risk of 1-year mortality with hazard ratios ranging from 3.75 (CI, 1.31-10.7) to 6.53 (CI 1.52-28.0, p ≤ 0.014 for all four). Positive predictive values of 1-year mortality were below 25% for all models.

CONCLUSION

In our analysis, the models we tested conferred modest incremental predicting power to ordinary screening methods.

Cardiac resynchronization therapy defibrillators in patients with permanent atrial fibrillation

Aims

There are conflicting data on the benefit of cardiac resynchronization therapy (CRT) in heart failure (HF) patients with permanent atrial fibrillation (AF). We aimed to compare patient outcomes according to the presence or absence of permanent AF at device implantation.

Methods and results

We retrospectively analysed remote monitoring data from 1141 CRT defibrillators. Propensity score with inverse‐probability weighting method was used to balance AF and sinus rhythm (SR) groups. Analysis endpoints included total mortality, appropriate defibrillation shocks, and CRT percentage. There were 229 patients (20.1%) in the AF group and 912 patients (79.9%) in the SR group. Compared with SR patients, AF patients were older (median age, 77 vs. 72 years, P < 0.001), more frequently male (82.5% vs. 75.5%, P = 0.02), and had higher heart rate (75.7 vs. 71.0 b.p.m., P < 0.001). Of the 229 AF patients, 162 (70.7%) received suboptimal CRT (<98%) and 67 (29.3%) had adequate CRT (≥98%). During a median follow‐up of 24 months, total mortality did not differ between AF and SR groups (propensity‐score‐weighted hazard ratio, HR 1.32 [95% confidence interval, 0.82–2.15], P = 0.25). The risk of appropriate shocks was significantly higher in the AF group with <98% CRT than in the SR group (weighted‐HR, 1.99 [1.21–3.26], P = 0.006) and was similar in the AF group with ≥98% CRT versus the SR group (1.29 [0.66–2.53], P = 0.45). During follow‐up, sinus rhythm was recovered in 23 patients in the AF group (10%) after a median time of 106 (42–256) days. The rate of sinus rhythm recovery in the AF group was 4.5 (95% CI, 2.8–6.7) per 100 patient‐years; the rate of permanent AF occurrence in the SR group was 2.5 (95% CI, 1.9–3.3) per 100 patient‐years.

Conclusions

Although mortality was similar across patient groups, patients with permanent AF and suboptimal CRT had twofold higher risk of appropriate shocks than SR patients or AF patients with CRT ≥ 98%.

Circadian periodicity affects the type of ventricular arrhythmias and efficacy of implantable defibrillator therapies

INTRODUCTION

Factors influencing malignant arrhythmia onset are not fully understood. We explored the circadian periodicity of ventricular arrhythmias (VAs) in patients with implantable cardioverter and cardiac resynchronization defibrillators (ICD/CRT-D).

METHODS

Time, morphology (monomorphic/polymorphic), and mode of termination (anti-tachycardia pacing [ATP] or shock) of VAs stored in a database of remote monitoring data were adjudicated. Episodes were grouped in six 4-h timeslots from 00:00 to 24:00. Circadian distributions and adjusted marginal odds ratios (ORs), with 95% confidence interval (CI), were analyzed using mixed-effect models and logit generalized estimating equations, respectively, to account for within-subject correlation of multiple episodes.

RESULTS

Among 1303 VA episodes from 446 patients (63% ICD and 37% CRT-D), 120 (9%) self-extinguished, and 842 (65%) were terminated by ATP, 343 (26%) by shock. VAs clustered from 08:00 to 16:00 with 44% of episodes, as compared with 22% from 00:00 to 08:00 (p < .001) and 34% from 16:00 to 24:00 (p = .005). Episodes were more likely to be polymorphic at night with an adjusted marginal OR of 1.66 (CI, 1.15-2.40; p = .007) at 00:00-04:00 versus other timeslots. Episodes were less likely to be terminated by ATP in the 00:00-04:00 (success-to-failure ratio, 0.67; CI, 0.46-0.98; p = .039) and 08:00-12:00 (0.70; CI, 0.51-0.96; p = .02) timeslots, and most likely to be terminated by ATP between 12:00 and 16:00 (success-to-failure ratio 1.42; CI, 1.06-1.91; p = .02).

CONCLUSION

VAs did not distribute uniformly over the 24 h, with a majority of episodes occurring from 08:00 to 16:00. Nocturnal episodes were more likely to be polymorphic. The efficacy of ATP depended on the time of delivery.

Combining left atrial appendage closure and catheter ablation for atrial fibrillation: 2-year outcomes from a multinational registry

AIMS

Clinical practice guidelines do not recommend discontinuation of long-term oral anticoagulation in patients with a high stroke risk after catheter ablation for atrial fibrillation (AF). Left atrial appendage closure (LAAC) with Watchman has emerged as an alternative to long-term anticoagulation for patients accepting of the procedural risks. We report on the long-term outcomes of combining catheter ablation procedures for AF and LAAC from multicentre registries.

METHODS AND RESULTS

Data were pooled from two prospective, real-world Watchman LAAC registries running in parallel in Europe/Middle-East/Russia (EWOLUTION) and Asia/Australia (WASP) between 2013 and 2015. Of the 1140 patients, 142 subjects at 11 centres underwent a concomitant AF ablation and LAAC procedure. The mean CHA2DS2-VASc score was 3.4 ± 1.4 and HAS-BLED score 1.5 ± 0.9. Successful LAAC was achieved in 99.3% of patients. The 30-day device and/or procedure-related serious adverse event rate was 2.1%. After a mean follow-up time of 726 ± 91 days, 92% of patients remained off oral anticoagulation. The rates of the composite endpoint of ischaemic stroke/transient ischaemic attack/systemic thromboembolism were 1.09 per 100 patient-years (100-PY); and for non-procedural major bleeding were 1.09 per 100-PY. These represent relative reductions of 84% and 70% vs. expected rates per risk scores.

CONCLUSION

The long-term outcomes from these international, multicentre registries show efficacy for all-cause stroke prevention and a significant reduction in late bleeding events in a population of high stroke risk post-ablation patients who have been withdrawn from oral anticoagulation.

Comparison of geographic workflow preferences with real-time dynamic regional mapping data during catheter ablation

Funding Acknowledgements

Type of funding sources: None.

Introduction

The clinical benefit of multielectrode high-density (HD) mapping during catheter ablation has been an area of active research. One advantage of HD mapping is improved sensitivity which can lead to better visualization and substrate delineation during the procedure. In addition to the advantages offered by the multielectrode grid mapping catheter (HD Grid), a novel software enable the display of beat-to-beat, dynamic regional mapping data from the current location of HD Grid in real-time (LiveView). The optimal settings and workflows to incorporate the dynamic data into routine ablation procedures have not been explored.

Purpose

To examine the common settings and workflow patterns among operators from different geographies when using dynamic mapping.

Methods

Observational procedural data including procedure time, total RF time, workflow preference, and fluoroscopy time, were prospectively collected from operators across Europe, the U.S., and Asia Pacific countries from May to September 2020. Cases from both catheter ablation of atrial and ventricular arrhythmias were included in the analysis.

Results

A total of 754 cases were collected (428, 133, and 193 cases from Europe, the U.S., and the Asia Pacific region, respectively). The most commonly reported indication across all three geographies was de novo paroxysmal atrial fibrillation (223/754, 30.0%). A steerable sheath was more frequently used with the mapping catheter in Europe and U.S. compared to Asia Pacific countries. Contrary to cases from the U.S. and Asia Pacific countries where the double transseptal approach was the preferred technique for left atrial procedures (78.8% and 55.3%, respectively), the single transseptal approach was more commonly observed in European cases (233/428, 54.4%). Visualization of real-time mapping data after creation of traditional full-chamber maps were commonly observed in all three geographies. Regardless of geography, the CS catheter was commonly used a reference electrode; and the most common map appearance settings for interior projection, exterior projection, and interpolation was 7, 7, and 7 respectively. Voltage cutoff of 0.1 mV, range from 0.01 to 1.5 mV, was most frequently observed for delineating scar in atrial arrhythmia cases analyzed in this dataset.

Conclusions

While there is a geographical difference in ablation workflow, common settings and patterns can be observed in all three regions. This data suggests that minimal workflow changes are required to incorporate the use of dynamic data into routine procedures. Adaptation of LiveView can help improve procedure efficiency and efficacy by reducing the need for full chamber maps, identifying areas that were under ablated, and confirming ablation endpoints. Further control study examining procedure efficiency and efficacy associated with dynamic mapping may be warranted.

Workflows and clinical utilization of dynamic mapping data in radiofrequency catheter ablation of cardiac arrhythmias

Funding Acknowledgements

Type of funding sources: None.

Introduction

Previous publications suggest that the use of high-density (HD) mapping leads to better substrate visualization and may lead to improved procedural outcomes. A novel dynamic mapping software, utilizes the HD grid mapping catheter (HD Grid) to display beat-to-beat, dynamic regional mapping data (LiveView). Incorporation of real-time dynamic mapping data into routine mapping/ablation workflows may further enhance the clinical benefits of HD mapping during radiofrequency (RF) catheter ablation procedures.

Purpose

 To examine the clinical utility and common workflows when dynamic mapping data was used during RF ablation procedures among operators with various experience levels.

Methods

Observational procedural data including procedure time, total RF time, and workflow preference were prospectively collected in catheter ablation cases utilizing LiveView from May to September 2020. Mapping and ablation strategies were determined at the operator’s discretion. Total percentage exceed 100% when multiple usage were reported.

Results

A total of 428 cases were collected from over 25 operators in 11 European countries. LiveView was used in a variety of cases including atrial fibrillation (paroxysmal and persistent), atrial flutter (typical and atypical), and VT (ischemic, non-ischemic, and idiopathic). Visualization of real-time mapping data from the current location of the HD Grid was commonly used after creation of traditional full-chamber maps (319/428, 74.5%). While operators in over 55% of the cases indicated that the use of dynamic display during mapping helped identify areas that were under ablated (238/428, 55.6%), using LiveView did not affect the lesion delivery strategies in those regions. LiveView was also used as a primary method for confirmation of pulmonary vein isolation (PVI) in 213 cases (49.8%). The most common reported usage of LiveView among the 428 cases analyzed was PVI confirmation/gap identification (75.2%), ablation line gap identification (41.1)%, and identification of breakthrough activation (23.6%)

Conclusions

This initial analysis demonstrated the diverse clinical utilization of LiveView dynamic display during RF catheter ablation procedures, including atrial and ventricular arrhythmias. Without causing significant changes to normal workflow, dynamic display of regional signals allows for rapid identification of ablation targets. When used during RF delivery, real-time assessment of regional activation patterns helped improve outcomes by rapidly identifying critical ablation location and ensuring successful lesion delivery. A further study that examines the impact of dynamic display on procedure efficacy may be warranted.

Transcatheter Aortic Valve Replacement in Young Low-Risk Patients With Severe Aortic Stenosis: A Review

In the last decades, transcatheter aortic valve replacement (TAVR) revolutionized the treatment of symptomatic severe aortic stenosis. The efficacy and safety of TAVR were first proven in inoperable and high-risk patients. Then, subsequent randomized clinical trials showed non-inferiority of TAVR as compared to surgical aortic valve replacement also in intermediate- and low-risk populations. As TAVR was progressively studied and clinically used in lower-risk patients, issues were raised questioning its opportunity in a younger population with a longer life-expectancy. As long-term follow-up data mainly derive from old studies with early generation devices on high or intermediate surgical risk patients, results can hardly be extended to most of currently treated patients who often show a low surgical risk and are treated with newer generation prostheses. Thus, in this low-risk younger population, decision making is difficult due to the lack of supporting data. The aim of the present review is to revise current literature regarding TAVR in younger patients.

Real-world reasons and outcomes for 1-month versus longer dual antiplatelet therapy strategies with a polymer-free BIOLIMUS A9-coated stent

BACKGROUND

A large trial established the favorable profile of a new polymer-free biolimus A9-eluting stent (PF-BES) with a 1-month dual antiplatelet therapy (DAPT) in high bleeding risk (HBR) patients. This is the first study comparing outcomes for a 1-month versus longer DAPT strategies following PF-BES-percutaneous coronary intervention (PCI).

METHODS

All patients undergoing PF-BES-PCI (January 2016 to July 2018) were included in the multicenter CHANCE registry. Patients were stratified according to DAPT strategy at discharge (planned 1-month vs. planned >1-month). Primary outcomes were the 390-day estimates of a patient-oriented and of a device-oriented composite endpoints (POCE: death, myocardial infarction [MI] or target vessel revascularization; DOCE: cardiac death, target vessel-MI or ischemia-driven target lesion revascularization). Landmark analyses from 1-month post-PCI were carried.

RESULTS

Following PF-BES-PCI, 328(40.3%) and 485(59.6%) patients were discharged with 1-month and longer DAPT (12 months [6-12]), respectively. Patients with a previous or index MI were less likely to be discharged on 1-month DAPT. Patients prescribed with 1-month DAPT were more likely to be at HBR than those with longer DAPT (90.2% vs. 69.9%, p = .001). No between-groups differences in the primary outcomes (planned 1-month vs. planned >1-month DAPT: POCE 11.9% vs. 13.2%, p = .747; DOCE: 4.8% vs. 8.1%, p = .500) were observed, also after adjusting for confoundings (POCE: adjusted-hazard ratio [adj-HR] 1.26, 95%CI 0.74-2.13; DOCE: adj-HR 1.00, 95%CI 0.49-1.99). Landmark analyses showed similar results.

CONCLUSIONS

In a large all-comers registry of PF-BES PCI, no interaction of planned DAPT strategy (1-month vs. >1-month) with outcomes was found. This observation warrants investigation in adequately powered randomized studies (ClinicalTrials.gov NCT03622203).

Real-World Experience With a Tapered Biodegradable Polymer-Coated Sirolimus-Eluting Stent in Patients With Long Coronary Artery Stenoses

Background

Treatment of long coronary stenoses (LCS) with long tapered drug-eluting stents (LT-DES) would offer clinical and economic benefits. However, the feasibility of an interventional strategy based upon the systematic LCS treatment with an LT-DES has not been evaluated so far.

Methods

We performed a multicenter prospective study including consecutive patients with: 1) An LCS > 25 mm at coronary angiography; 2) An attempt to fix the LCS with a single BioMime Morph™ stent, a novel LT-DES available from 30 to 60 mm long. The primary efficacy endpoint was procedural success. The secondary safety endpoints were post-procedural TIMI3 flow, stent detachment during delivery, acute stent thrombosis and in-hospital mortality.

Results

From February 2017 to March 2018, we recorded 272 patients with an LCS and an attempt to deploy an LT-DES during percutaneous coronary intervention (PCI) (69.3 ± 11.4 years, 75.7% males, 25.7% diabetic and 43.8% with acute coronary syndromes, mean LCS length 48.8 ± 9.5 mm). LT-DES deployment was successful in 262 patients (96.3%), and failure occurred without stent detachment or other complications. Final TIMI3 flow was present in 270 (99.3%) patients. In-hospital death occurred in five patients (1.8%), with no case of acute stent thrombosis, recurrent myocardial infarction or repeated revascularization.

Conclusion

In this real-world study, a strategy of fixing LCS with a single LT-DES was feasible and safe, with a high rate of procedural success and a low rate of in-hospital complications. More extensive randomized studies are warranted to assess the potential clinical and economic benefits of LT-DES.

[Care path for non-deferred elective hospitalizations in cardiology in the Covid-19 period]

. Care path for non-deferred elective hospitalizations in cardiology in the Covid-19 period.

INTRODUCTION

The novel coronavirus-19 (Covid-19) has rapidly resulted in a global pandemic. Our hospital had to postpone all elective admissions to increase capacity for COVID-19 patients. Therefore, a rearrangement of the elective admissions was necessary to guarantee a restart of ordinary procedures.

AIM

To describe the organizational model adopted for elective procedures during the Covid-19 pandemic, to guarantee maximum safety for patients and healthcare workers.

METHODS

Patients on waiting list for cardiac procedures were rearranged based on risks prioritization. Procedure of coronary angiography and cardiac devices (PM and ICD) implants or replacement took priority upon other cardiac procedures. Each patient underwent a telephone nurse triage to assess for any covid-19 symptoms. The hospital admissions were organized in accordance with health and safety measures declared by the National Institute of Health, with different paths according to the swab results.

RESULTS

A total of 66 patients were contacted and 40 accepted the hospital admission (26 refused it, for fear of infection or covid-19 related family problems). No patient resulted positive to the nasal swab.

CONCLUSIONS

In view of the impact on the health care system of this new pandemic, the choice of an appropriate pathway which can preserve patients' safety is essential, while guaranteeing the treatment of problems, such as cardiovascular diseases, with a high mortality rate.

P531Cardiac resynchronization therapy in patients with permanent atrial fibrillation: insights from the HMEA database

Funding Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Background/Introduction: The benefits of cardiac resynchronization therapy with defibrillator (CRT-D) in heart failure are well established. However, a gap of evidence is still present for patients with permanent atrial fibrillation (perm-AF)

Purpose

To investigate outcomes of CRT-D patients with perm-AF in terms of appropriate shock for ventricular arrhythmia and all-cause mortality in a long-term time horizon. 

Methods

We used the Home Monitoring Expert Alliance (HMEA) database, a nationwide data repository of daily remote monitoring transmissions. The episodes with delivered shock were adjudicated by a board of 3 electrophysiologists.

Results

Among 1226 CRT-D patients (mean age 71.2 ± 10.0 years; 75.5% males), 276 (22.5%) had perm-AF at device implantation. These patients had more frequently rate responsive function (19.7% vs 64.1%) and higher basic rate (median value 60 bpm vs 70 bpm) as compared to all other patients (p &lt; 0.001). The CRT pacing percentage calculated over the first 2 months was slightly lower for perm-AF patients (median value 96.0% vs 98.8%, p &lt; 0.001).

At 5-year appropriate shock incidence was 34.2% (95% confidence interval [CI], 25.1%-45.3%) for perm-AF and 19.9% (15.6%-25.1%) for all other patients. All-cause mortality was 27.7% (17.7%-41.8%) for perm-AF and 15.6% (12.2%-19.9%) for all other patients. 

The age- and sex-adjusted hazard ratio between perm-AF and all other patients was 1.81 (95% CI: 1.25-2.64, p = 0.002) for appropriate shock and 0.92 (95% CI: 0.57-1.50, p = 0.748) for all-cause mortality.

Conclusion

Although a higher incidence of appropriate shock, perm-AF at the time of CRT-D implantation was not associated with increased long-term mortality,

Abstract Figure. Appropriate shock and mortality

WorldwIde SurvEy on Clinical and Anatomical Factors Driving the Choice of Transcatheter Aortic Valve pRostheses

Background: Following the success of the first human transcatheter aortic valve replacement (TAVR) in 2002, multiple transcatheter heart valves (THVs) have become available. However, guidelines or expert consensus on how to optimize THV choice according to patients' anatomical and clinical characteristics is missing. This survey-based study aimed to identify patient-specific characteristics deemed important in the choice of THV type.

Methods and results: A web-based survey including 39 questions was completed by 71 experienced TAVR operators from 23 countries with a median TAVR volume of 88 procedures in the year prior to survey completion (IQR 61-180). The survey covered five topics: access, aortic annulus/leaflets, aortic root, left ventricular function and clinical characteristics. Factors with the most impact on THV choice were reported to be a calcified sinotubular junction, valve-in-valve procedure, annular dimension >575 mm², femoral diameter ≤ 5.0 mm, low coronary ostia, calcification at the annular level and/or protruding into the left ventricular outflow tract, and need for post TAVR PCI. Also, in case of off-label use of THVs to treat bicuspid aortic valve disease and isolated aortic regurgitation, the choice of THV type was reported to be important.

Conclusions: This survey-based study identifies key patient characteristics that impact THV selection. As such, we present a guide, based on current practice, of which THV types are best suited to these different patient-specific characteristics. A patient-tailored THV choice is likely to optimize TAVR outcomes.

Atrial signal amplitude predicts atrial high-rate episodes in implantable cardioverter defibrillator patients: Insights from a large database of remote monitoring transmissions

BACKGROUND

Parameters measured during implantable cardioverter defibrillator (ICD) implant also depend on bioelectrical properties of the myocardium. We aimed to explore their potential association with clinical outcomes in patients with single/dual-chamber ICD and cardiac resynchronization therapy defibrillator (CRT-D).

METHODS

In the framework of the Home Monitoring Expert Alliance, baseline electrical parameters for all implanted leads were compared by the occurrence of all-cause mortality, adjudicated ventricular arrhythmia (VA), and atrial high-rate episode lasting ≥24 hours (24 h AHRE).

RESULTS

In a cohort of 2976 patients (58.1% ICD) with a median follow-up of 25 months, event rates were 3.1/100 patient-years for all-cause mortality, 18.1/100 patient-years for VA, and 9.3/100 patient-years for 24 h AHRE. At univariate analysis, baseline shock impedance was consistently lower in groups with events than without, with a 40 Ω cutoff that better identified high-risk patients. However, at multivariable analysis, the adjusted-hazard ratios (HRs) lost statistical significance for any endpoint. Baseline atrial sensing amplitude during sinus rhythm was lower in patients with 24 h AHRE than in those without (2.45 [IQR: 1.65-3.85] vs 3.51 [IQR: 2.37-4.67] mV, P < .01). The adjusted HR for 24 h AHRE in patients with atrial sensing >1.5 mV vs those with values ≤1.5 mV was 0.52 (95% CI: 0.33-0.83), P = .006.

CONCLUSIONS

Although lower baseline shock impedance was observed in patients with events, the association lost statistical significance at multivariable analysis. Conversely, low sinus rhythm atrial sensing (≤1.5 mV) measured with standard transvenous leads could identify subjects at high risk of atrial arrhythmia.

Cryoballoon Ablation in Patients With Paroxysmal Atrial Fibrillation: An Evaluation of Cohorts With and Without Structural Heart Disease

BACKGROUND

Pulmonary vein isolation (PVI) is the most widely adopted strategy for paroxysmal atrial fibrillation (PAF) ablation. Limited evidence on acute results and late outcomes of cryoballoon (CB)-PVI in patients with structural heart disease (SHD) exist. The aim of this analysis was to compare acute procedural results and the 1-year recurrence rate of a single CB-PVI procedure in a PAF population with and without SHD.

METHOD

From April 2012 to May 2017, a total of 2,031 patients with AF underwent CB-PVI and were followed prospectively in the framework of the One Shot TO Pulmonary vein isolation (1STOP) ClinicalService project, involving 36 Italian cardiology centres. We identified patients with SHD according to criteria proposed by current ESC guidelines: left ventricular (LV) systolic or diastolic dysfunction, long-standing hypertension with LV hypertrophy, and/or other structural heart disease. Data on procedural outcomes and long-term freedom from AF recurrence were evaluated.

RESULTS

Our population consisted of 1,452 patients, of whom 282 (19.4%) were classified as having SHD. Compared to non-SHD patients, the SHD cohort was older (mean ± standard deviation, 62.9 ± 9.0 vs 58.2 ± 11.4 years; p < 0.001), was more frequently male (79.1% vs 69.8%; p < 0.002), had a higher thrombo-embolic risk (CHA₂DS₂VASc ≥2: 63.4% vs 40.2%; p < 0.001), had a higher body mass index (27.7 ± 3.9 vs 26.4 ± 3.9 kg/m²; p < 0.001), had a larger atrial diameter (43.8 ± 7.0 vs 40.2 ± 5.8 mm; p < 0.001), and had a lower LV ejection fraction (57.2 ± 7.7% vs 60.7 ± 6.0%; p < 0.001). At the time of ablation, 73% of patients were on class Ic or III anti-arrhythmic drugs. Procedure time (106.9 ± 41.5 vs 112.1 ± 46.8 min; p = 0.248), fluoroscopic time (28.7 ± 14.7 vs 28.6 ± 15.2 min; p = 0.819), and complication rate (3.9% vs 4.8%; p = 0.525) were not different between the SHD and non-SHD cohorts. However, the acute success rate (98.9% vs 97.7%; p = 0.016) was higher in patients with SHD. After a follow-up of 13.4 ± 12.8 months, freedom from symptomatic recurrence was 78.0% for SHD and 78.4% for non-SHD (p = 0.895). Recurrence rate was not related to either left atrial size or LVEF. In the SHD cohort, Class Ic or III anti-arrhythmic drugs treatment decreased from 70.7% of patients before ablation to 28.7% of patients after CB-PVI (p = 0.001).

CONCLUSIONS

CB-PVI was extensively applied to treat patients with PAF. Unlike previous PVI experiences, the acute success and recurrence rate after a single procedure was not related to the presence of SHD or to the degree of cardiac remodelling. Further studies are required to define whether CB-PVI has a useful role in patients with a significantly reduced ejection fraction as those patients were under-represented in the current population.

Are Atrial High-Rate Episodes Associated With Increased Risk of Ventricular Arrhythmias and Mortality?

OBJECTIVES

This study evaluated the temporal association between atrial high-rate episodes (AHREs) and sustained ventricular arrhythmias (VAs) in a remotely monitored cohort with implantable cardioverter-defibrillators (ICD) with and/or without cardiac resynchronization therapy with a defibrillator (CRT-D).

BACKGROUND

Clinical relevance of AHREs in terms of VA rate and survival has not been outlined yet.

METHODS

This study analyzed data of patients with ICDs and CRT-Ds from the nationwide Home Monitoring Expert Alliance network. The cohort included 2,435 patients with a median follow-up of 25 months (interquartile range: 13 to 42 months) and age 70 years (range 61 to 77 years); 19.7% were women, 51.4% had coronary artery disease, and 45.2% had a CRT-D. There were 3,410 appropriate VA episodes; 498 (14.6%) were preceded by AHREs within 48 h; in 85.5% of this group, AHREs were still ongoing at episode onset.

RESULTS

In a longitudinal analysis, the odds ratios (ORs) of experiencing any VA in a 30-day interval with AHREs versus intervals without AHREs were 2.35 (95% confidence interval [CI]: 1.86 to 2.97; p < 0.001) for ventricular tachycardia (VT), 3.06 (95% CI: 2.35 to 3.99; p < 0.001) for fast VT, 1.84 (95% CI: 1.36 to 2.48; p < 0.001) for self-extinguishing ventricular fibrillation (VF), and 2.31 (95% CI: 1.17 to 4.57; p = 0.01) for VF. ORs decreased with increasing AHRE burden. Patients with AHREs 48 h before VAs were more likely to experience VA recurrences (adjusted hazard ratio [HR]: 1.78; 95% CI: 1.41 to 2.24; p < 0.001) and had higher overall mortality (HR: 2.67; 95% CI: 1.68 to 4.23; p < 0.001).

CONCLUSIONS

AHREs were not uncommon 48 h before VAs, which tended to be distributed around intervals with AHREs. Temporal connection between AHREs and VAs was a marker of increased risk of VA recurrence and a poorer prognosis.

[A case of pulmonary artery sarcoma and review of the literature]

Pulmonary artery sarcoma (PAS) is a highly malignant tumor that originates in the pulmonary artery. This disease has a poor prognosis. Early diagnosis followed by radical surgical resection constitutes the only chance of survival for patients. However, owing to the rare and nonspecific clinical manifesta-tions and imaging findings, PAS is frequently misdiagnosed as various pulmonary thromboembolic diseases. We report the case of a 49-year-old woman who presented to our emergency department for dyspnea, hemoptysis, cough, and asthenia. A diagnosis of pulmonary thromboembolism was initially postulated. However, the rapid clinical progression of the disease, characterized by multiorgan involvement, together with the persistence of pulmonary filling defects despite appropriate anticoagulation therapy, induced to a late diagnosis of metastasized PAS. The peculiarity of our case consists of two main factors: the first is the atypical clinical presentation characterized by severe neurological impairment that finally led to patient's death; the second is the histopathological aspect of the lesion with a prevalent histiocytic cell component that is described in the literature as the less frequent pathological variant of this tumor.

Rate-responsive pacing and atrial high rate episodes in cardiac resynchronization therapy patients: Is low heart rate the key?

BACKGROUND

The role of atrial rate-responsive (RR) pacing in cardiac resynchronization therapy (CRT) is unclear due to the favorable effect of rate lowering in systolic heart failure. Atrial high rate episodes (AHREs) in CRT recipients are particularly worrisome since they cause loss of CRT, beyond representing a stroke risk factor.

HYPOTHESIS

The presence of an association between RR and the incidence of AHREs.

METHODS

Daily remote transmissions from 836 CRT recipients were analyzed. AHREs were classified by duration: ≥15 minutes, ≥5 hours, and ≥ 24 hours. Variables possibly associated to AHREs were included in time-dependent proportional-hazard models, averaging over 30-day periods and adjusting for main baseline variables.

RESULTS

After a median follow-up of 23.9 (12.2-36.0) months, 507 (60.6%) patients experienced at least one 15-minute AHRE. RR function was programmed in 166 (19.8%) patients and was associated with an increased AHRE occurrence rate with hazard ratio (HR) ranging from 1.45 to 1.78 for the 3 cutoffs of episode duration. The negative effect of RR function was not observed in the subset of patients with low mean heart rate (<68 bpm). Higher mean heart rates increased AHRE risk (HR:1.02, P = .01), while CRT amount decreased it (HR:0.98, P < .01). The extent of atrial pacing did not predict AHRE occurrence.

CONCLUSIONS

RR pacing in CRT recipients is associated with increased AHRE occurrence, especially when an average heart rate > 68 bpm is attained.

[Combined left atrial appendage percutaneous closure and atrial fibrillation ablation: a single center experience]

BACKGROUND

We evaluated long-term safety and efficacy of concomitant left atrial appendage (LAA) closure and atrial fibrillation (AF) ablation.

METHODS

From February 2013 to June 2017, all patients referred for AF ablation and LAA closure (group 1) were enrolled in the study and compared with a matched control group undergoing AF ablation only (group 2). Pulmonary vein isolation was achieved in all cases with radiofrequency or cryoballoon. LAA was occluded with Watchman or Amplatzer Cardiac Plug or Amulet (ACP) devices. All patients were treated with oral anticoagulation therapy for at least 3 months after the procedure ("blanking period"), and then switched to dual antiplatelet therapy with aspirin and clopidogrel for other 3 months, and then to single antiplatelet therapy with aspirin in case of LAA closure, while group 2 was treated with long-term oral anticoagulation therapy according to CHA2DS2-VASc score. Follow-up was performed with transesophageal echocardiography and clinical visit at 3, 6 and 12 months after the procedure. AF burden was evaluated by loop recorder or pacemaker interrogation in all patients.

RESULTS

Overall, 42 patients were enrolled, 21 in each group. Mean age was 66.86 ± 10.35 years in group 1 vs 68.42 ± 10.61 in group 2 (p=NS); mean CHA2DS2-VASc score was 2.8 ± 1.22 in group 1 vs 2.01 ± 0.93 in group 2 (p=NS), mean HAS-BLED score was 3.2 ± 0.83 in group 1 vs 3.1 ± 0.95 in group 2 (p=NS). Persistent AF was present in 80% of patients in group 1 and in 85% in group 2. LAA closure was successful in all cases (14 Watchman, 7 ACP devices). Procedural and fluoroscopy times were shorter in group 2 (68 ± 17 vs 52 ± 15 min, p <0.05; 23 ± 5 vs 18 ± 3 min, p <0.05, respectively). No procedural complications were observed in group 2, while in group 1 one case of self-terminating pericardial effusion and one arteriovenous fistula were observed. At a mean follow-up of 14.93 ± 10.05 months, complete seal of LAA was documented in all patients, with neither dislocations nor thromboembolic events. Similarly, no long-term complications were observed in group 2. Maintenance of sinus rhythm was overlapping, with an AF relapse rate of 36% in group 1 vs 38% in group 2 (p=NS).

CONCLUSIONS

Combined LAA percutaneous closure and AF ablation appears to be feasible in high-risk patients.

Long-term outcomes after prophylactic ICD and CRT-D implantation in nonischemic patients: Analysis from a nationwide database of daily remote-monitoring transmissions

INTRODUCTION

Clinical trials did not provide conclusive evidence concerning the benefit of prophylactic implantable cardioverter-defibrillators (ICDs) in patients with severe nonischemic cardiomyopathy (NICM). We aimed to compare incidence of appropriate sustained ventricular arrhythmia (SVA) and device therapy in ischemic cardiomyopathy (ICM) vs NICM ICD and/or cardiac resynchronization therapy (CRT-D) patients.

METHODS AND RESULTS

We analyzed remote-monitoring data from devices of the Home Monitoring Expert Alliance network. SVA recordings were adjudicated by three independent electrophysiologists. Our cohort included 1,946 patients who received either an ICD (55%) or a CRT-D (45%) for primary prevention of sudden cardiac death. Median (interquartile range) age was 70 (62-77) years, 81% were male, and 52% were in the ICM group. Patients were remotely monitored for a maximum follow-up of 5 years. The 5-year product-limit estimate of SVA incidence in patients with an ICD was 47.3% (95% confidence interval [CI], 41.0%-53.9%) in the ICM group and 44.7% (36.9%-53.3%) in the NICM group. In patients with a CRT-D, SVA incidence was 45.7% (37.3%-55.0%) in ICM patients and 49.2% (40.4%-58.7%) in NICM patients. The adjusted hazard ratio for SVA in the ICM vs NICM group was 0.96 (95% CI: 0.70-1.30, P = .77) in ICD patients and 0.85 (95% CI: 0.61-1.18, P = .34) in CRT-D patients. SVAs triggered appropriate device therapies with similar incidence in all groups.

CONCLUSION

In a large cohort of remotely monitored ICD and CRT-D recipients, SVA incidence did not significantly differ in ICM and NICM patients.

Combining Watchman left atrial appendage closure and catheter ablation for atrial fibrillation: multicentre registry results of feasibility and safety during implant and 30 days follow-up

Aims

Long-term results from catheter ablation therapy for atrial fibrillation (AF) remain uncertain and clinical practice guidelines recommend continuation of long-term oral anticoagulation in patients with a high stroke risk. Left atrial appendage closure (LAAC) with Watchman has emerged as an alternative to long-term anticoagulation for patients accepting of the procedural risks. We report on the initial results of combining catheter ablation procedures for AF and LAAC in a multicentre registry.

Methods and results

Data were pooled from two prospective, real-world Watchman LAAC registries running in parallel in Europe/Middle-East/Russia (EWOLUTION) and Asia/Australia (WASP) between 2013 and 2015. Of the 1140 patients, 139 subjects at 10 centres underwent a concomitant AF ablation and LAAC procedure. The mean CHA2DS2-VASc score was 3.4 ± 1.4 and HAS-BLED score 1.5 ± 0.9. Successful Watchman implantation was achieved in 100% of patients. The overall 30-day serious adverse event (SAE) rate was 8.7%, with the device and/or procedure-related SAE rate of 1.4%. One pericardial effusion required percutaneous drainage, but there were no strokes, device embolization, or deaths at 30 days. The 30-day bleeding SAE rate was 2.9% with 55% of patients prescribed NOAC and 38% taking warfarin post-procedure.

Conclusion

The outcomes from these international, multicentre registries support the feasibility and safety of performing combined procedures of ablation and Watchman LAAC for patients with non-valvular AF and high stroke risk. Further data are needed on long-term outcomes for the hybrid technique on all-cause stroke and mortality.

Is the time between first diagnosis of paroxysmal atrial fibrillation and cryoballoon ablation a predictor of efficacy?

AIMS

Cryoablation is an indicated therapy for the treatment of recurrent atrial fibrillation through pulmonary vein isolation; however, the optimal time between first diagnosis of atrial fibrillation and cryoablation is still unknown. We aimed to assess the clinical efficacy and safety of early versus later treatment of patients with paroxysmal atrial fibrillation by cryoablation.

METHODS

Five hundred and ten patients underwent atrial fibrillation cryoablation and were prospectively followed for at least 6 months in 43 Italian cardiology centers. The population was divided into two groups according to the time since the first diagnosis of atrial fibrillation until the index cryoablation procedure. An early-treatment group had an elapsed time of 15 months or less from atrial fibrillation diagnosis until cryoablation, and the late-treatment group had an elapsed time of greater than 15 months. During the evaluation, clinical efficacy was defined as atrial fibrillation recurrence outside a landmark 90-day blanking period, and safety was defined as the reporting of all procedure-related complications.

RESULTS

In the total cohort, cryoablation was performed after a median of 36 months from the point of the patient diagnosis with drug refractory symptomatic recurrent atrial fibrillation. The early-treatment group was composed of 130 (25%) patients, whereas the late-treatment group had 380 (75%) patients. Both cohorts had similar baseline clinical characteristics. Of 510 patients, 22 had a complication related to the procedure with no difference between the two groups. Multivariable analysis showed that the risk of atrial fibrillation recurrence was significantly higher in the late-treatment group (hazard ratio: 1.77; 95% confidence interval 1.00-3.13) CONCLUSION: In our multicenter observational examination, cryoablation was well tolerated and effective in the treatment of patients with drug refractory symptomatic paroxysmal atrial fibrillation. Reducing the time between diagnosis and ablation brought about a treatment that had a lower risk of atrial fibrillation recurrence with no change in safety.(Italian ClinicalService Project: NCT01007474).

Cryoballoon ablation of atrial fibrillation is effectively feasible without previous imaging of pulmonary vein anatomy: insights from the 1STOP project

BACKGROUND

Pulmonary vein isolation by cryoablation (PVI-C) is a standard therapy for the treatment of atrial fibrillation (AF); however, PVI-C can become a challenging procedure due to the anatomy of the left atrium and pulmonary veins (PVs). Importantly, the utility of imaging before the procedure is still unknown regarding the long-term clinical outcomes following PVI-C. The aim of the analysis is to evaluate the impact of imaging before PVI-C on procedural data and AF recurrence.

METHODS

Patients with paroxysmal AF underwent an index PVI-C. Data were collected prospectively in the framework of 1STOP ClinicalService® project. Patients were divided into two groups according to the utilization of pre-procedural imaging of PV anatomy (via CT or MRI) or the non-usage of pre-procedural imaging.

RESULTS

Out of 912 patients, 461 (50.5%) were evaluated with CT or MRI before the PVI-C and denoted as the imaging group. Accordingly, 451 (49.5%) patients had no pre-procedural imaging and were categorized as the no imaging group. Patient baseline characteristics were comparable between the two cohorts, but the ablation centers that comprised the imaging group had fewer PVI-C cases per year than the no imaging group (p < 0.001). The procedure, fluoroscopy, and left atrial dwell times were significantly shorter in the no imaging cohort (p < 0.001). The rates of complications were significantly greater in the imaging group compared to the no imaging group (6.9% vs. 2.7%; p = 0.003); this difference was attributed to differences in transient diaphragmatic paralysis. The 12-month freedom from AF was 76.2% in the imaging group and 80.0% in the no imaging group (p = 0.390).

CONCLUSIONS

In our analysis, PVI-C was effective regardless of the availability of imaging data on PV anatomy.

Multimodality imaging for thromboembolic risk assessment in atrial fibrillation

: Atrial fibrillation is the most widely represented sustained arrhythmia in the world. Thromboembolic risk assessment represents the main clinical challenge associated with this condition, requiring enormous medical, social and economical efforts. Several pieces of evidence in literature highlight how clinical risk factors are not enough for a correct thromboembolic risk stratification of patients with atrial fibrillation, since thromboembolic events have been proven to occur even in patients with low clinical risk scores. A comprehensive multimodality imaging approach, with special regard to echocardiography and new technologies seems to be the best method for this purpose. The aim of this review is to propose a hybrid thromboembolic risk stratification system that combinines clinical evaluation with instrumental clues on left atrial remodeling, fibrosis and deformation which, could be useful especially for patients classified at low thromboembolic risk according to clinical scores.

[Appropriateness criteria for the management of anticoagulant therapy in complex patients with atrial fibrillation. The opinion of a group of expert Italian cardiologists]

Atrial fibrillation (AF) is a common arrhythmia often associated with high thromboembolic risk. The purpose of this position paper is to provide clinicians with recommendations useful in managing some important issues regarding the use of anticoagulant therapy in patients with AF in particularly complex clinical situations.The RAND/UCLA appropriateness method, validated to combine the best available scientific evidence with the collective judgment of experts, was used to assess the judgment of an expert panel of cardiologists. To this purpose, the benefit-to-harm ratio of 37 clinical scenarios was rated. Each indication was classified as "appropriate", "uncertain", or "inappropriate" in accordance with the panelists' median score.The present document reports the results of this consensus process, which led to the development of recommendations for clinical practice on how to use anticoagulant therapy in patients with AF in complex clinical settings, including the presence of comorbidities, cardioversion, or ablation. Non-vitamin K oral anticoagulants are a valid alternative to vitamin K antagonists in preventing embolic events in patients with non-valvular AF, particularly in case of clinical complexity.

A comparison of 8-mm and open-irrigated gold-tip catheters for typical atrial flutter ablation: Data from a prospective multicenter registry

BACKGROUND

Cavotricuspid isthmus (CTI) radiofrequency (RF) catheter ablation is the standard treatment for patients suffering from CTI-dependent atrial flutter (AFL). The aim of this study was to compare the use in clinical practice of 8-mm gold-tip catheter (8mmRFC) and open-irrigated gold-tip catheter (irrRFC) for RF typical AFL ablation.

METHODS

Patients with typical AFL were treated with 8mmRFC or irrRFC catheters according to investigator preferences. The primary endpoint was the cumulative radiofrequency time (CRFT). Fluoroscopy time, acute and 6-month success rates were secondary endpoints.

RESULTS

After excluding 3 patients with left AFL, 157 of the enrolled patients (median age 71.8 [interquartile range, 64.1-76.2], 76% men, 91% in NYHA class ≤II, 65% with no structural heart disease) were analyzed: 74 (47%) subjects were treated with the 8mmRFC and 83 (53%) with the irrRFC. The median CRFT was 3 [2-6] minutes in the 8mmRFC group and 5 [3-7] minutes in the irrRFC group (P = .183). There were no significant differences in ablation success rates, intraprocedural CTI reconnections, audible steam pops, and procedural times. In the 8mmRFC group, a significantly lower fluoroscopy time was observed as compared to the irrRFC group (8 [5-12] vs 15 [10-20] minutes, P < .001). During the follow-up period, AFL recurrences were documented in 3 patients in the 8mmRFC group and 2 in the irrRFC group (P = .655).

CONCLUSIONS

The 8mmRFC and the irrRFC performed similarly in routine practice for CTI ablation in terms of cumulative RF time, acute and 6-month success rates. Fluoroscopy time was significantly lower in the 8mmRFC group.

Does the CHA2DS2-VASc score reliably predict atrial arrhythmias? Analysis of a nationwide database of remote monitoring data transmitted daily from cardiac implantable electronic devices

BACKGROUND

CHA₂DS₂-VASc is a validated score for predicting stroke in patients with atrial fibrillation (AF).

OBJECTIVE

The purpose of this study was to assess whether the CHA₂DS₂-VASc score can predict new-onset AF in a cohort of patients with a cardiac implantable electronic device (CIED) followed with remote monitoring.

METHODS

Using the database of the Home Monitoring Expert Alliance project, we selected 2410 patients with no documented AF who had received a CIED with diagnostics on atrial high rate episodes (AHREs). The primary endpoint was time to first day with cumulative AHRE burden ≥15 minutes, 5 hours, 24 hours, and ≥7 consecutive days.

RESULTS

During a median duration of 24.1(11.5-42.9) months, the incidence of AHRE increased with increasing CHA₂DS₂-VASc. At 6 years, occurrence of ≥15-minute AHRE was 80.2% (CHA₂DS₂-VASc ≤1) vs 93.7% (CHA₂DS₂-VASc ≥5), whereas ≥5-hour AHRE incidence was 68.4% (CHA₂DS₂-VASc ≤1) vs 92.5% (CHA₂DS₂-VASc ≥5). Occurrence of ≥24-hour and ≥7-day AHREs also increased with increasing CHA₂DS₂-VASc: 9.1% and 3.9% (CHA₂DS₂-VASc ≤1) vs 40.4% and 28.7% (CHA₂DS₂-VASc ≥5), respectively. Adjusted hazard ratio for unitary CHA₂DS₂-VASc increase ranged from 1.09 (confidence interval 1.04-1.14; P <.001) with AHRE burden ≥15 minutes to 1.26 (confidence interval 1.11-1.42; P <.001) with AHRE burden ≥7 days. At receiver operating curve analysis, CHA₂DS₂-VASc ≥2 was estimated to predict persistent forms of AHREs with 95.8% sensitivity but 11.7% specificity at 3 years. CHA₂DS₂-VASc ≥5 had 77.0% specificity but 34.6% sensitivity.

CONCLUSION

In a CIED population with no previous diagnosis of clinical AF, AHRE incidence increased with increasing CHA₂DS₂-VASc score. The association was stronger with longer AHREs, but the accuracy of CHA₂DS₂-VASc as AHRE predictor was moderate.

An Unusual Case of Aortic-Right Atrium Fistula: A Diagnostic and Therapeutic Challenge

An aorta-to-right atrium (RA) fistula is an anomalous communication between the ascending or descending thoracic aorta and the RA. In this report, we describe a case of an idiopathic aortic root-to-RA fistula occasionally found during a coronary angiography performed in a young patient admitted for acute chest pain with evidence of multivessel coronary artery disease. The anatomical peculiarity of this fistulous communication is that it gave origin to collateral vessels furnishing the inferolateral wall of the left ventricle. The case represented a diagnostic and therapeutic challenge that required a multimodality imaging and a multidisciplinary team approach.

Pulmonary Vein Isolation with the Cryoballoon Technique: Feasibility, Procedural Outcomes, and Adoption in the Real World: Data from One Shot Technologies TO Pulmonary Vein Isolation (1STOP) Project

BACKGROUND

Catheter ablation (CA) is recommended for patients with drug refractory symptomatic atrial fibrillation (AF). "One Shot" catheters have been introduced to simplify CA and cryoballoon ablation (CBA) is spreading rapidly. Few real-world data are available on standard clinical practice, mainly from single-center experience. We aimed to evaluate clinical settings, demographics, and acute procedural outcomes in a large cohort of patients treated with CBA.

METHODS

A total of 903 patients (73% male, mean age 59 ± 11) underwent pulmonary vein CBA. Correlations between the patient's inclusion time and clinical characteristics, procedure duration, acute success rate, and intraprocedural complications were evaluated.

RESULTS

Seventy-seven percent of patients were affected by paroxysmal AF and 23% by persistent AF. Overall, acute success rate was 97.9% and periprocedural complications were observed in 35 (3.9%) patients, 13 (1.4%) of which were classified as major complications. With respect to the patient's inclusion time analysis, an increase in treatment of persistent AF was observed, a significant decrease in CBA times (procedure, ablation, and fluoroscopy: 136.0 ± 46.5 minutes, 28.8 ± 19.6 minutes, and 34.3 ± 15.4 minutes, respectively) was observed, with comparable acute success rate and intraprocedural complications over time. The rate of major complications was extremely low (1.4%); no death, atrioesophageal fistula, stroke, or other major periinterventional or late complications occurred.

CONCLUSION

This series represents the largest experience of CBA in the treatment of AF that also describes the adoption curve of this relatively recent technology. CBA showed an excellent safety profile when performed in a large real-world clinical setting, with satisfactory acute success rate and, on average, short procedural times.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov (NCT01007474).