Prevalence and distribution of non-pulmonary vein atrial fibrillation triggers in real-world clinical settings

Background

Epidemiology of non-pulmonary vein (PV) triggers of atrial fibrillation (AF) is not fully known.

Purpose

This study aimed to clarify the prevalence and distribution of non-PV triggers in real-world clinical settings of AF catheter ablation.

Methods

One-thousand and twenty patients undergoing AF ablations were retrospectively analyzed (mean age 65 years old, 702 males (69%), 506 paroxysmal and 514 non-paroxysmal). Induction and observation of AF triggers were attempted using intravenous isoproterenol/adenosine triphosphate and repeated direct current cardioversion during AF in each session. Documentable non-PV AF triggers were characterized in the studied population. Premature atrial contractions that did not initiate AF were excluded.

Results

A hundred and twenty-six non-PV triggers were documented in 108 patients (10.6%). Non-PV trigger was documented in 6.3% of 1st session cases, whereas 30.9% of recurrent cases undergoing multiple sessions (p<0.0001). Left atrial (LA) posterior wall was the most prevalent site (N=34), followed by 30 intra-atrial septum (IAS), 29 superior vena cava (SVC), 13 crista terminalis, 7 right atrial (RA) free wall, 6 LA anterior wall, 3 coronary sinus (CS), 3 left atrial appendage, and 1 persistent left superior vena cava (LSVC). We classified those non-PV triggers into 4 groups; 43 LA, 33 thoracic veins (SVC, CS and LSVC), 30 IAS and 20 RA. Thoracic vein/RA origins were more prevalently detected in paroxysmal AF cases (57%) compared to non-paroxysmal AF (28%) (p<0.01). Conversely, LA origin was more prevalently detected in non-paroxysmal AF cases (48%) compared to paroxysmal AF (20%) (p<0.01).

Conclusions

Prevalence of non-PV trigger in cases undergoing multiple sessions is extremely high, suggesting a particular importance of non-PV trigger targeting in patients with recurrent AF undergoing 2nd or 3rd ablation sessions. Progressive nature of AF with newly generated AF triggers should be under consideration. Distributions of non-PV triggers are largely different between paroxysmal and non-paroxysmal AF. These findings may help ablation strategy regarding non-PV trigger targeting in practice.

Funding Acknowledgement

Type of funding sources: None.

Aggressive combined pharmacotherapy for heart failure reduces new onset atrial fibrillation

Backgrounds

Heart failure (HF) is a risk factor for new onset atrial fibrillation (AF), and the new onset AF is associated with a worse prognosis in HF patients. It has been reported that renin-angiotensin system inhibitor (RASi), β-blocker and mineral-corticoid receptor antagonist (MRA) prevent the new onset AF in HF patients. However, the effect of combined pharmacotherapy including angiotensin receptor neprilysin inhibitor (ARNI) and sodium glucose co-transporter 2 inhibitor (SGLT2i) on AF is unknown. We investigated the impact of contemporary regimen of combined pharmacotherapy for HF (RASi/ARNI+β-blocker+MRA+SGLT2i) on new onset AF.

Methods and results

We retrospectively studied rEF and mrEF patients without AF admitted to our hospital due to decompensated HF between 2015 and 2021 (n=366). Long-term (The mean follow-up was 635±421 days) incidence of new onset AF was investigated with regard to medical therapies. Patients were divided into 2 groups; patients with ≤2 HF drugs (n=181) and patients with ≥3 HF drugs (n=185). Patients with ≤2 HF drugs group were older (77.3 vs 67.0 years old, P<0.001), had a poorer renal function (Cre: 1.66 vs 1.09 mg/dl, P<0.001), and had a higher rate of ischemic heart disease (52 vs 38%, P=0.009), whereas left ventricular systolic function was better (EF: 31.9 vs 27.3%, P<0.001). There were 19 (10.5%) new onsets AF in the ≤2 HF drugs group, whereas only 7 (3.8%) had new onsets AF in the ≥3 HF drugs group (HR 0.36, 95% CI 0.15–0.85, P=0.01). All-cause death and hospitalization for HF were fewer in the ≥3 HF drugs group. A multivariate analysis revealed that ≥3 HF drugs use was an independent negative predictor of new onset AF (HR 0.37, 95% CI 0.15–0.93, P=0.03). Even after a propensity score matching of the clinical variables, the incidence of new onset AF was consistently fewer in the ≥3 HF drugs group (HR 0.36, 95% CI 0.13–0.99, P=0.04). Finally, patients with new onset AF had a higher rate of hospitalization for HF in the studied population (HR 9.68, 95% CI 5.67–16.5, P<0.01).

Conclusion

Aggressive combined pharmacotherapy for HF may be associated with fewer new onset AF in patients with HF.

Funding Acknowledgement

Type of funding sources: None.

A case report of serologically diagnosed pulmonary anisakiasis with pleural effusion and multiple lesions

The second known human case of pulmonary anisakiasis is reported. A 22-years-old man living in Hyuga City, Miyazaki Prefecture, Japan, developed high fever, respiratory distress, and pleural effusion after consumption of raw fish. Although his total white blood cell count increased to approximately 10,000-20,000/mm3, eosinophilia was not observed. The total IgE level in his serum markedly increased up to 3,599 IU/ml. Since the patient was suspected to have a parasitic disease, immunoserologic tests were carried out. Screening tests using a multiple dot-enzyme-linked immunosorbent assay (ELISA) and an Ouchterlony double-diffusion test showed that his serum and pleural effusion had the strongest reactivity against crude antigen of Anisakis type I larvae, together with weak cross-reactivity against several other nematode antigens. Since extragastrointestinal anisakiasis was strongly suspected, this diagnosis was confirmed by a microplate-ELISA and Western blot analysis using a monoclonal antibody.

[Therapy of hepatocellular carcinoma with UFT--clinical evaluation of its effect in the combination therapy with transcatheter arterial embolization or one shot therapy]

In 55 hepatocellular carcinoma patients treated with transcatheter arterial embolization or one shot therapy, the prognosis of patients treated with UFT (group A; n = 23) were historically compared with those of patients treated without UFT (group B; n=32). In group A, survival rate was 91.3% at 6 month; 67.5% at 1-year, 24.3% at 2-year, 24.3% at 3 year, in group B, 59.4% at 6-month, 37.5% at 1 year, 16.1% at 2-year. In these comparison, group A revealed significantly higher survival rate than group B. These results indicated that UFT was effective as maintenance therapy after transcatheter arterial embolization or one shot therapy with hepatocellular carcinoma.

Intracranial and orbital metastasis of hepatocellular carcinoma: report of two cases

Two cases of rare intracranial and orbital metastasis of hepatocellular carcinoma are presented. A 61-year-old woman was found to have a metastatic tumor in the right temporo-occipital lobe 1 year after undergoing treatment for a primary hepatoma. An osteolytic tumor was removed from the left orbit of a 58-year-old man and the primary tumor, a hepatoma, was discovered postoperatively. The intracranial and orbital tumors were verified to be hepatocellular carcinoma. Both patients died within 1 year of surgery. The relevant literature is briefly reviewed.