Lower Recurrence Rates of Atrial Fibrillation and MACE Events After Early Compared to Late Ablation: A Danish Nationwide Register Study

BACKGROUND

Guidelines recommend prioritizing treatment with antiarrhythmic drugs before referral of patients with atrial fibrillation to ablation, delaying a potential subsequent ablation. However, delaying ablation may affect ablation outcomes. We sought to investigate the impact of duration from diagnosis to ablation on the risk of atrial fibrillation recurrence and adverse events.

METHODS AND RESULTS

Using Danish nationwide registries, all patients with first-time ablation for atrial fibrillation were identified and included from 2010 to 2018. Patients were divided into 4 groups by diagnosis-to-ablation time: <1.0 year (early ablation), 1.0 to 1.9 years, 2.0 to 2.9 years, and >2.9 years (late ablation). The primary end point was atrial fibrillation recurrence after the 90-day blanking period, defined by admission for atrial fibrillation, cardioversions, use of antiarrhythmic drugs, or repeat atrial fibrillation ablations. The secondary end point was a composite end point of heart failure, ischemic stroke, or death, and each event individually. The study cohort consisted of 7705 patients. The 5-year cumulative incidence of atrial fibrillation recurrence in the 4 groups was 42.9%, 54.8%, 55.9%, and 58.4%, respectively. Hazard ratios were 1.20 (95% CI, 1.07-1.35), 1.29 (95% CI, 1.13-1.47), and 1.40 (95% CI, 1.28-1.53), respectively, with the early ablation group as reference. The hazard ratio for the combined secondary end point was 1.22 (95% CI, 1.04-1.44) in the late ablation group compared with the early ablation group.

CONCLUSIONS

In patients undergoing ablation for atrial fibrillation, early ablation was associated with a significantly lower risk of atrial fibrillation recurrence. Furthermore, the associated risk of heart failure, ischemic stroke, or death was significantly lower in early-compared with late-ablation patients.

Durability of Pulmonary Vein Isolation Using Pulsed-Field Ablation: Results From the Multicenter EU-PORIA Registry

BACKGROUND

Pulsed-field ablation (PFA) is a novel nonthermal ablation technology with high procedural safety and efficiency for pulmonary vein isolation (PVI). Premarket data showed high PVI durability during mandatory remapping studies. Data on lesion durability in real-world patients with clinically indicated redo procedures are scarce.

OBJECTIVES

This study sought to report PVI durability rates in patients undergoing a clinically indicated redo procedure after an index PVI using PFA.

METHODS

Patients from 7 European centers undergoing an index PVI using PFA were included the EU-PORIA (European Real-world Outcomes With Pulsed Field Ablation in Patients With Symptomatic Atrial Fibrillation) registry. In patients with subsequent left atrial redo procedures due to arrhythmia recurrence, 3-dimensional electroanatomical maps were acquired. PVI durability was assessed on a per-vein and per-patient level, and sites of reconnections and predictors of lesion durability were identified.

RESULTS

Of 1,184 patients (62% paroxysmal atrial fibrillation) undergoing an index PVI using PFA, 272 (23%) had an arrhythmia recurrence. Of these, 144 (53%) underwent a left atrial redo procedure a median of 7 (Q1-Q3: 5-10) months after the first ablation. Three-dimensional electroanatomical maps identified 404 of 567 pulmonary veins (71%) with durable isolation. In 54 patients (38%), all pulmonary veins were durably isolated. Prior operator experience with cryoballoon ablation was associated with a higher PVI durability compared to operators with only point-by-point radiofrequency experience (76% vs 60%; P < 0.001). Neither the operators' cumulative experience in atrial fibrillation ablation (≤5 vs >5 years) nor the size of the PFA device used (31 mm vs 35 mm) had an impact on subsequent lesion durability (both P > 0.50).

CONCLUSIONS

In 144 patients with arrhythmia recurrence after PFA PVI, durable isolation was observed in 71% of the pulmonary veins during the redo procedure, and 38% of all patients showed durable isolation of all veins.

Pain trajectories and neuropathic pain symptoms following lung cancer surgery: A prospective cohort study

BACKGROUND

Persistent postsurgical pain (PPSP) after lung cancer surgery is common and current definitions are based on evaluations at a single time point after surgery. Pain intensity and symptoms may however fluctuate and change over time, and be impacted by multiple and shifting factors. Studies of postoperative recovery patterns and transition from acute to chronic pain are needed for further investigation of preventive measures and treatments to modify unfavourable recovery paths.

METHODS

In this explorative study, 85 patients undergoing surgery due to either presumptive or confirmed lung cancer reported pain intensities bi-monthly for 12 months. Pain trajectories during recovery were investigated, using group-based trajectory modelling. Associations with possible risk factors for PPSP, including clinical variables and anxiety and depression score (HADS), were also explored.

RESULTS

A trajectory model containing three 12-month pain recovery groups was computed. One group without PPSP fully recovered (50%) within two to three months. Another group with mild-intensity PPSP followed a protracted recovery trajectory (37%), while incomplete recovery was observed in the last group (13%). Acute postoperative pain and younger age were associated with a less favourable recovery trajectory. More neuropathic pain symptoms were observed in patients with incomplete recovery.

CONCLUSIONS

Three clinically relevant recovery trajectories were identified, based on comprehensive pain tracking. Higher acute postoperative pain intensity was associated with an unfavourable pain recovery trajectory.

SIGNIFICANCE STATEMENT

Understanding the transition from acute to chronic postoperative pain and identifying preoperative risk factors is essential for the development of targeted treatments and the implementation of preventive measures. This study (1) identified distinct recovery trajectories based on frequent pain assessment follow-ups for 12 months after surgery and (2) evaluated risk factors for unfavourable postoperative pain recovery paths. Findings suggest that early higher postoperative pain intensity is associated with an unfavourable long-term recovery path.

Long-term outcomes of the pentaspline pulsed-field ablation catheter for the treatment of paroxysmal atrial fibrillation: results of the prospective, multicentre FARA-Freedom Study

AIMS

Pulmonary vein isolation (PVI) is a well-established strategy for the treatment of paroxysmal atrial fibrillation (PAF). Despite randomized controlled trials and real-world data showing the promise of pulsed-field ablation (PFA) for this treatment, long-term efficacy and safety data demonstrating single-procedure outcomes off antiarrhythmic drugs remain limited. The aim of the FARA-Freedom Study was to evaluate the long-term efficacy and safety of PFA using the pentaspline catheter for PAF.

METHODS AND RESULTS

FARA-Freedom, a prospective, non-randomized, multicentre study, enrolled patients with PAF undergoing de novo PVI with PFA, who were followed for 12 months with weekly transtelephonic monitoring and a 72-h Holter ECG at 6 and 12 months. The primary safety endpoint was a composite of device- or procedure-related serious adverse events out to 7 days post-ablation and PV stenosis or atrioesophageal (AE) fistula out to 12 months. Treatment success is a composite of acute PVI and chronic success, which includes freedom from any documented atrial tachyarrhythmia longer than 30 s, use of antiarrhythmic drugs or cardioversion after a 3-month blanking period, or use of amiodarone or repeat ablation at any time. The study enrolled 179 PAF patients (62 ± 10 years, 39% female) at 13 centres. At the index procedure, all PVs were successfully isolated with the pentaspline PFA catheter. Procedure and left atrial dwell times, with a 20-min waiting period, were 71.9 ± 17.6 and 41.0 ± 13.3 min, respectively. Fluoroscopy time was 11.5 ± 7.4 min. Notably, monitoring compliance was high, with 88.4 and 90.3% with weekly events and 72-h Holter monitors, respectively. Freedom from the composite primary effectiveness endpoint was 66.6%, and 41 patients had atrial tachyarrhythmia recurrence, mostly recurrent atrial fibrillation (31 patients). The composite safety endpoint occurred in two patients (1.1%), one tamponade and one transient ischaemic attack. There was no coronary spasm, PV stenosis, or AE fistula. There were four cases of transient phrenic nerve palsy, but all resolved during the index procedure.

CONCLUSION

In this prospective, non-randomized, multicentre study, PVI using a pentaspline PFA catheter was effective in treating PAF patients despite rigourous endpoint definitions and high monitoring compliance and demonstrated favourable safety.

REGISTRATION

Clinical Trials.gov Identifier: NCT05072964 (sponsor: Boston Scientific Corporation).

Characterization of durability and reconnection patterns at time of repeat ablation after single-shot pulsed field pulmonary vein isolation

BACKGROUND

Pulsed field ablation (PFA) is a novel method of cardiac ablation where there is insufficient knowledge on the durability and reconnection patterns after pulmonary vein isolation (PVI). The aim of this study was to characterize the electrophysiological findings at time of repeat procedure in real-world atrial fibrillation (AF) patients.

METHODS

Patients who underwent a repeat procedure (n=26) for symptomatic recurrent arrhythmias after index first-time treatment with single-shot PFA PVI (n=266) from July 2021 to June 2023 were investigated with 3D high-density mapping and ad-hoc re-ablation by radiofrequency or focal PFA.

RESULTS

Index indication for PVI was persistent AF in 17 (65%) patients. The mean time to repeat procedure was 292 ± 119 days. Of the 26 patients (104 veins), complete durable PVI was observed in 11/26 (42%) with a durable vein isolation rate of 72/104 (69%). Two patients (8%) had all four veins reconnected. The posterior wall was durably isolated in 4/5 (80%) of the cases. The predominant arrhythmia mechanism was AF in 17/26 (65%) patients and regular atrial tachycardia (AT) in 9/26 (35%). Reconnection was observed 9/26 (35%) in right superior, 11/26 (42%) in right inferior, 7/26 (27%) in left superior, 5/26 (19%) in left inferior, p=0.31 between veins. The gaps were significantly clustered in the right-sided anterior carina compared to other regions (P=0.009).

CONCLUSIONS

Durable PVI was observed in less than half of the patients at time of repeat procedure. No significant difference in PV reconnection pattern was observed, but the gap location was preferentially located at the anterior aspects of the right-sided PVs. Predominant recurrence was AF. More data is needed to establish lesion formation and durability and AT circuits after PFA.

Impact of Left Atrial Posterior Wall Ablation During Pulsed-Field Ablation for Persistent Atrial Fibrillation

BACKGROUND

Pulmonary vein isolation (PVI) alone is insufficient to treat many patients with persistent atrial fibrillation (PersAF). Adjunctive left atrial posterior wall (LAPW) ablation with thermal technologies has revealed lack of efficacy, perhaps limited by the difficulty in achieving lesion durability amid concerns of esophageal injury.

OBJECTIVES

This study aims to compare the safety and effectiveness of PVI + LAPW ablation vs PVI in patients with PersAF using pulsed-field ablation (PFA).

METHODS

In a retrospective analysis of the MANIFEST-PF (Multi-National Survey on the Methods, Efficacy, and Safety on the Post-approval Clinical Use of Pulsed Field Ablation) registry, we studied consecutive PersAF patients undergoing post-approval treatment with a pentaspline PFA catheter. The primary effectiveness outcome was freedom from any atrial arrhythmia of ≥30 seconds. Safety outcomes included the composite of acute and chronic major adverse events.

RESULTS

Of the 547 patients with PersAF who underwent PFA, 131 (24%) received adjunctive LAPW ablation. Compared to PVI-alone, patients receiving adjunctive LAPW ablation were younger (65 vs 67 years of age, P = 0.08), had a lower CHA2DS2-VASc score (2.3 ± 1.6 vs 2.6 ± 1.6, P = 0.08), and were more likely to receive electroanatomical mapping (48.1% vs 39.0%, P = 0.07) and intracardiac echocardiography imaging (46.1% vs 17.1%, P < 0.001). The 1-year Kaplan-Meier estimate for freedom from atrial arrhythmias was not statistically different between groups in the full (PVI + LAPW: 66.4%; 95% CI: 57.6%-74.4% vs PVI: 73.1%; 95% CI: 68.5%-77.2%; P = 0.68) and propensity-matched cohorts (PVI + LAPW: 71.7% vs PVI: 68.5%; P = 0.34). There was also no significant difference in major adverse events between the groups (2.2% vs 1.4%, respectively, P = 0.51).

CONCLUSIONS

In patients with PersAF undergoing PFA, as compared to PVI-alone, adjunctive LAPW ablation did not improve freedom from atrial arrhythmia at 12 months.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Focal pulsed field ablation and ultrahigh-density mapping - versatile tools for all atrial arrhythmias? Initial procedural experiences

BACKGROUND

Focal pulsed field ablation (FPFA) is a novel and promising method of cardiac ablation. The aim of this study was to report the feasibility, short-term safety, and procedural findings for a broad spectrum of ablated atrial arrhythmias.

METHODS

Patients (n = 51) scheduled for ablation of atrial arrhythmias were prospectively included and underwent FPFA using the Galvanize CENTAURI generator with energy delivery through commercially available ablation catheters with ultrahigh-density (UHDx) 3D electroanatomic voltage/local activation time map evaluations. Workflow, procedural data, and peri-procedural technical errors and complications are described.

RESULTS

Planned ablation strategy was achieved with FPFA-only in 48/51 (94%) of the cases. Ablation strategy was first-time pulmonary vein isolation (PVI) in 17/51 (36%), repeat ablation in 18/51 (38%), PVI + in 13/51 (28%), and cavotricuspid isthmus block (CTI)-only in 3/51 (6%). The mean procedure time was 104 ± 31 min (first-time PVI), 114 ± 26 min (repeat procedure), 152 ± 36 min (PVI +), and 62 ± 17 min (CTI). Mean UHDx mapping time to assess lesion formation and block after ablation was 7 ± 4 min with 5485 ± 4809 points. First pass acute (linear) isolation with bidirectional block for anatomical lesion sets was 120/124 (97%) for all PVs, 17/17 (100%) for (any) isthmus, and 14/17 (82%) for left atrium posterior wall (LAPW). We observed several time-consuming integration errors with the used ablation system (mean 3.4 ± 3.7 errors/procedure), one transient inferior ST elevation when ablating CTI resolved by intravenous nitroglycerine and one transient AV block requiring temporary pacing for > 24 h.

CONCLUSIONS

FPFA was a highly versatile method to treat atrial arrhythmias with high first-pass efficiency. UHDx revealed acute homogenous low-voltage lesions in ablated areas. More data is needed to establish lesion durability and limitations of FPFA.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Two decades of SVT ablation in Denmark: a trend towards higher age, more comorbidity, and less prior use of antiarrhythmic and rate-limiting pharmacotherapy-a nationwide registry-based Danish study

BACKGROUND AND AIMS

Trends in patient selection and use of pharmacotherapy prior to catheter ablation (CA) for supraventricular tachycardia (SVT) are not well described. This study examined temporal trends in patients undergoing first-time CA for regular SVT, including atrioventricular nodal re-entry tachycardia (AVNRT), accessory pathways (APs), and ectopic atrial tachycardia (EAT) on a nationwide scale in Denmark in the period 2001-2018.

METHODS AND RESULTS

Using Danish Nationwide registers, 9959 patients treated with first-time CA for SVT between 2001 and 2018 were identified, of which 6023 (61%) received CA for AVNRT, 2829 (28%) for AP, and 1107 (11%) for EAT. Median age was 55, 42, and 55 in the AVNRT, APs, and EAT group, respectively. The number of patients receiving CA increased from 1195 between 2001 and 2003 to 1914 between 2016 and 2018. The percentage of patients with a CHA2DS2-VASc score ≥ 2 increased in all patient groups. The number of patients who underwent CA with no prior use of antiarrhythmic- or rate limiting medicine increased significantly, though prior use of beta-blockers increased for AVNRT patients. Use of verapamil decreased in all three SVT groups (P < 0.05). Use of amiodarone and class 1C antiarrhythmics remained low, with the highest usage among EAT patients.

CONCLUSION

Between 2001 and 2018, CA was increasingly performed in patients with SVT, primarily AVNRT- and EAT patients. The burden of comorbidities increased. Patients undergoing CA without prior antiarrhythmic- or rate-limiting drug therapy increased significantly. Use of beta-blockers increased and remained the most widely used drug.

Early recurrence of atrial tachyarrhythmia indicates pulmonary vein reconduction independent of blanking period duration in the RACE-AF trial

INTRODUCTION

Atrial tachyarrhythmia recurrence during the blanking period (early ATA) after pulmonary vein isolation (PVI) is associated with an increased risk of later recurrence, but its relationship with pulmonary vein reconduction (PVR) is poorly understood. The objective of the present study was to evaluate the relationship between early ATA and PVR. Second, to provide data on the optimal blanking period by (a) evaluating how the predictive values of ATA for PVR are affected by blanking period duration, and (b) assessing the temporal development in atrial fibrillation (AF) burden.

METHODS

In this RACE-AF substudy, 91 patients with paroxysmal AF undergoing PVI randomized to radiofrequency or cryoballoon ablation were included. All patients received an implantable cardiac monitor and underwent a protocol-mandated repeat procedure after 4-6 months for assessment of PVR. ATA ≥ 30 s. ≤ 90 days after PVI constituted early ATA.

RESULTS

PVR was found in 37/54 (69%) patients with early ATA and in 11/37 (30%) patients without (p < .001). The positive predictive value of ATA for PVR was independent of blanking period duration (range 0-90 days). In both patients with and without PVR, AF burden was higher in the first month after PVI, but AF burden from the second month was similar to AF burden after the conventional blanking period.

CONCLUSION

Early ATA indicates PVR, and the positive predictive value is independent of the blanking period duration. Altogether, the results of this study support substantially shortening the blanking period after PVI for paroxysmal AF.

Clinical Outcomes by Sex After Pulsed Field Ablation of Atrial Fibrillation

Importance

Previous studies evaluating the association of patient sex with clinical outcomes using conventional thermal ablative modalities for atrial fibrillation (AF) such as radiofrequency or cryoablation are controversial due to mixed results. Pulsed field ablation (PFA) is a novel AF ablation energy modality that has demonstrated preferential myocardial tissue ablation with a unique safety profile.

Objective

To compare sex differences in patients undergoing PFA for AF in the Multinational Survey on the Methods, Efficacy, and Safety on the Postapproval Clinical Use of Pulsed Field Ablation (MANIFEST-PF) registry.

Design, Setting, and Participants

This was a retrospective cohort study of MANIFEST-PF registry data, which included consecutive patients undergoing postregulatory approval treatment with PFA to treat AF between March 2021 and May 2022 with a median follow-up of 1 year. MANIFEST-PF is a multinational, retrospectively analyzed, prospectively enrolled patient-level registry including 24 European centers. The study included all consecutive registry patients (age ≥18 years) who underwent first-ever PFA for paroxysmal or persistent AF.

Exposure

PFA was performed on patients with AF. All patients underwent pulmonary vein isolation and additional ablation, which was performed at the discretion of the operator.

Main Outcomes and Measures

The primary effectiveness outcome was freedom from clinically documented atrial arrhythmia for 30 seconds or longer after a 3-month blanking period. The primary safety outcome was the composite of acute (<7 days postprocedure) and chronic (>7 days) major adverse events (MAEs).

Results

Of 1568 patients (mean [SD] age, 64.5 [11.5] years; 1015 male [64.7%]) with AF who underwent PFA, female patients, as compared with male patients, were older (mean [SD] age, 68 [10] years vs 62 [12] years; P < .001), had more paroxysmal AF (70.2% [388 of 553] vs 62.4% [633 of 1015]; P = .002) but had fewer comorbidities such as coronary disease (9% [38 of 553] vs 15.9% [129 of 1015]; P < .001), heart failure (10.5% [58 of 553] vs 16.6% [168 of 1015]; P = .001), and sleep apnea (4.7% [18 of 553] vs 11.7% [84 of 1015]; P < .001). Pulmonary vein isolation was performed in 99.8% of female (552 of 553) and 98.9% of male (1004 of 1015; P = .90) patients. Additional ablation was performed in 22.4% of female (124 of 553) and 23.1% of male (235 of 1015; P = .79) patients. The 1-year Kaplan-Meier estimate for freedom from atrial arrhythmia was similar in male and female patients (79.0%; 95% CI, 76.3%-81.5% vs 76.3%; 95% CI, 72.5%-79.8%; P = .28). There was also no significant difference in acute major AEs between groups (male, 1.5% [16 of 1015] vs female, 2.5% [14 of 553]; P = .19).

Conclusion and Relevance

Results of this cohort study suggest that after PFA for AF, there were no significant sex differences in clinical effectiveness or safety events.

Pulsed field ablation in real-world atrial fibrillation patients: clinical recurrence, operator learning curve and re-do procedural findings

BACKGROUND

Pulsed field ablation (PFA) is a novel method of cardiac ablation demonstrated in early pre-clinical and clinical settings. The aim of this study was to report the safety and clinical efficacy of pulmonary vein isolation (PVI) with PFA for real-world atrial fibrillation (AF) patients.

METHODS

All-comer AF patients (n = 121, 59% paroxysmal) were prospectively included and underwent PFA with 100% high-density voltage maps performed after PVI. Clinical outcomes were gathered by chart review.

RESULTS

PVI was achieved with PFA-only in 119 (98%) of the cases. During the implementation phase the mean procedure and fluoroscopy time was reduced from 85 ± 34 to 72 ± 18 min (p = 0.044) and 22 ± 9 to 16 ± 4 (p = 0.034). We observed one phrenic nerve palsy with only partial remission at follow-up. Other adverse events were numerically comparable to standard PVI procedures. Over a mean follow-up of 308 ± 87 days, a total of 22/121 (18.2%) cases experienced clinically significant recurrence or initiation of anti-arrhythmic drugs with Kaplan-Meier event-free estimate at 365 days of 80% (88% for paroxysmal versus 69% for persistent). In five of eight re-do procedures, gaps were primarily located at the right pulmonary veins.

CONCLUSIONS

PFA was a highly efficient method to achieve PVI with reductions in procedure time and fluoroscopy over the implementation period. The procedural data and clinical recurrence rates from initial trials were confirmed in real-life non-selected AF patients. More data is needed to establish lesion durability and limitations of PFA.

Repeated deep-inspiration breath-hold CT scans at planning underestimate the actual motion between breath-holds at treatment for lung cancer and lymphoma patients

PURPOSE/OBJECTIVE

Deep-inspiration breath-hold (DIBH) during radiotherapy may reduce dose to the lungs and heart compared to treatment in free breathing. However, intra-fractional target shifts between several breath-holds may decrease target coverage. We compared target shifts between four DIBHs at the planning-CT session with those measured on CBCT-scans obtained pre- and post-DIBH treatments.

MATERIAL/METHODS

Twenty-nine lung cancer and nine lymphoma patients were treated in DIBH. An external gating block was used as surrogate for the DIBH-level with a window of 2 mm. Four DIBH CT-scans were acquired: one for planning (CTDIBH3) and three additional (CTDIBH1,2,4) to assess the intra-DIBH target shifts at scanning by registration to CTDIBH3. During treatment, pre-treatment (CBCTpre) and post-treatment (CBCTpost) scans were acquired. For each pair of CBCTpre/post, the target intra-DIBH shift was determined. For lung cancer, tumour (GTV-Tlung) and lymph nodes (GTV-Nlung) were analysed separately. Group mean (GM), systematic and random errors, and GM for the absolute maximum shifts (GMmax) were calculated for the shifts between CTDIBH1,2,3,4 and between CBCTpre/post.

RESULTS

For GTV-Tlung, GMmax was larger at CBCT than CT in all directions. GMmax in cranio-caudal direction was 3.3 mm (CT)and 6.1 mm (CBCT). The standard deviations of the shifts in the left-right and cranio-caudal directions were larger at CBCT than CT. For GTV-Nlung and CTVlymphoma, no difference was found in GMmax or SD.

CONCLUSION

Intra-DIBH shifts at planning-CT session are generally smaller than intra-DIBH shifts observed at CBCTpre/post and therefore underestimate the intra-fractional DIBH uncertainty during treatment. Lung tumours show larger intra-fractional variations than lymph nodes and lymphoma targets.

Association Between Pulmonary Vascular Volume and Cardiac Structure and Function in Patients With Atrial Fibrillation

Pulmonary vascular abnormalities, quantified from computed tomography scans, have frequently been observed in patients with pulmonary diseases. However, little is known about pulmonary vascular changes in patients with cardiac disease. Thus, we aimed to examine the cardiopulmonary relation in patients with atrial fibrillation (AF) by comparing pulmonary vascular volume (PVV) to echocardiographic measures and AF severity. A total of 742 patients (median age 63 years, 70% men) who underwent ablation for AF were included. Preprocedural cardiac computed tomography was used to measure the total and small-vessel PVV, along with the pulmonary artery to aorta ratio and the degree of emphysema. The association between PVV and echocardiographic parameters was evaluated using a multivariable linear regression analysis. Lower total and small-vessel PVV were associated with more impaired measures of cardiac structure and function, including but not limited to left ventricular ejection fraction and peak atrial longitudinal strain. Patients with reduced total and small-vessel PVV had higher odds of having persistent AF than paroxysmal AF in the unadjusted logistic regression analyses. However, after clinical and echocardiographic adjustments, only reduced small-vessel PVV remained independently associated with persistent AF (odds ratio 1.90, 95% confidence interval 1.26 to 2.87, p = 0.002). In conclusion, pulmonary vascular remodeling is associated with persistent AF and with more impaired measures of cardiac structure and function, providing further insights into heart-lung interactions in this patient group.

Prevalence of sleep apnea in unselected patients with atrial fibrillation by a home-monitoring device: The DAN-APNO study

Background

Sleep apnea (SA), a modifiable risk factor in - atrial fibrillation (AF), is associated with worse outcomes in AF. We aimed to assess the prevalence and severity of SA in patients with AF, and, subsequently, to assess the positive predictive value (PPV) of moderate to severe SA by a home-monitoring device in comparison to cardio-respiratory monitoring (CRM) in consecutive patients with AF.

Methods

This cross-sectional study recruited unselected patients with AF without known SA from an out-patient clinic at Department of Cardiology, Herlev-Gentofte University Hospital. Participants underwent four consecutive nights of sleep-recording with the home-monitoring device NightOwl™ (NO). Moderate SA was defined as an Apnea-Hypopnea Index (AHI) of 15-29 and severe SA as ≥ 30 AHI. Participants with moderate to severe SA was offered CRM for validation of the diagnosis.

Results

We included 126 patients with AF with a median age of 68 (interquartile range: 60-75) years, 42 (33 %) women, 70 (56 %) hypertension, 61 (48 %) hyperlipidemia and 49 (39 %) heart failure. NO detected severe SA in 36 (29 %) of patients with AF, moderate SA in 35 (28 %), mild SA in 45 (36 %) and no SA in 10 (8 %). Of 71 patients with moderate to severe SA by NO, 38 patients underwent CRM and the PPV of NO was 0.82 (31/38) to diagnose moderate SA and 0.92 (22/24) to diagnose severe SA by CRM.

Conclusion

Moderate to severe SA by NO was highly prevalent in patients with AF without known SA. A home-monitoring device such as NO could be an easy and feasible SA screening tool in patients with AF.

EUropean real-world outcomes with Pulsed field ablatiOn in patients with symptomatic atRIAl fibrillation: lessons from the multi-centre EU-PORIA registry

AIMS

Pulsed field ablation (PFA) is a new, non-thermal ablation modality for pulmonary vein (PV) isolation in patients with atrial fibrillation (AF). The multi-centre EUropean Real World Outcomes with Pulsed Field AblatiOn in Patients with Symptomatic AtRIAl Fibrillation (EU-PORIA) registry sought to determine the safety, efficacy, and learning curve characteristics for the pentaspline, multi-electrode PFA catheter.

METHODS AND RESULTS

All-comer AF patients from seven high-volume centres were consecutively enrolled. Procedural and follow-up data were collected. Learning curve effects were analysed by operator ablation experience and primary ablation modality. In total, 1233 patients (61% male, mean age 66 ± 11years, 60% paroxysmal AF) were treated by 42 operators. In 169 patients (14%), additional lesions outside the PVs were performed, most commonly at the posterior wall (n = 127). Median procedure and fluoroscopy times were 58 (interquartile range: 40-87) and 14 (9-21) min, respectively, with no differences due to operator experience. Major complications occurred in 21/1233 procedures (1.7%) including pericardial tamponade (14; 1.1%) and transient ischaemic attack or stroke (n = 7; 0.6%), of which one was fatal. Prior cryoballoon users had less complication. At a median follow-up of 365 (323-386) days, the Kaplan-Meier estimate of arrhythmia-free survival was 74% (80% for paroxysmal and 66% for persistent AF). Freedom from arrhythmia was not influenced by operator experience. In 149 (12%) patients, a repeat procedure was performed due to AF recurrence and 418/584 (72%) PVs were durably isolated.

CONCLUSION

The EU-PORIA registry demonstrates a high single-procedure success rate with an excellent safety profile and short procedure times in a real-world, all-comer AF patient population.

Safety and Effectiveness of Pulsed Field Ablation to Treat Atrial Fibrillation: One-Year Outcomes From the MANIFEST-PF Registry

BACKGROUND

Pulsed field ablation is a novel nonthermal cardiac ablation modality using ultra-rapid electrical pulses to cause cell death by a mechanism of irreversible electroporation. Unlike the traditional ablation energy sources, pulsed field ablation has demonstrated significant preferentiality to myocardial tissue ablation, and thus avoids certain thermally mediated complications. However, its safety and effectiveness remain unknown in usual clinical care.

METHODS

MANIFEST-PF (Multi-National Survey on the Methods, Efficacy, and Safety on the Post-Approval Clinical Use of Pulsed Field Ablation) is a retrospective, multinational, patient-level registry wherein patients at each center were prospectively included in their respective center registries. The registry included all patients undergoing postapproval treatment with a multielectrode 5-spline pulsed field ablation catheter to treat atrial fibrillation (AF) between March 1, 2021, and May 30, 2022. The primary effectiveness outcome was freedom from clinical documented atrial arrhythmia (AF/atrial flutter/atrial tachycardia) of ≥30 seconds on the basis of electrocardiographic data after a 3-month blanking period (on or off antiarrhythmic drugs). Safety outcomes included the composite of acute (<7 days postprocedure) and latent (>7 days) major adverse events.

RESULTS

At 24 European centers (77 operators) pulsed field ablation was performed in 1568 patients with AF: age 64.5±11.5 years, female 35%, paroxysmal/persistent AF 65%/32%, CHA₂DS₂-VASc 2.2±1.6, median left ventricular ejection fraction 60%, and left atrial diameter 42 mm. Pulmonary vein isolation was achieved in 99.2% of patients. After a median (interquartile range) follow-up of 367 (289-421) days, the 1-year Kaplan-Meier estimate for freedom from atrial arrhythmia was 78.1% (95% CI, 76.0%-80.0%); clinical effectiveness was more common in patients with paroxysmal AF versus persistent AF (81.6% versus 71.5%; P=0.001). Acute major adverse events occurred in 1.9% of patients.

CONCLUSIONS

In this large observational registry of the postapproval clinical use of pulsed field technology to treat AF, catheter ablation using pulsed field energy was clinically effective in 78% of patients with AF.

Differential gap location after radiofrequency versus cryoballoon pulmonary vein isolation: Insights from a randomized trial with protocol-mandated repeat procedure

INTRODUCTION

Reconnections to pulmonary vein (PV) triggers of atrial fibrillation (AF) are the primary cause of AF recurrence after PV isolation (PVI) with radiofrequency (RF) or cryoballoon catheter ablation (CRYO), but method-specific contributions to PV reconduction pattern and conductive gap location are incompletely understood.

METHODS

The objective of this radiofrequency versus cryoballoon catheter ablation for paroxysmal atrial fibrillation substudy was to determine procedure-specific patterns of PV reconduction in a randomized population with protocol-mandated repeat procedures, irrespective of AF recurrence. Each PV was assessed in turn and PV reconnection sites were identified by high-density electroanatomical mapping and locating the earliest activation site. Gap locations were verified by PV re-isolation.

RESULTS

In 98 patients, 81% versus 76% previously isolated PVs remained isolated after CRYO versus RF (risk ratio [RR]: 1.06; 95% confidence interval [CI]: 0.96-1.18; p = .28). There were no significant differences for any PV: left superior PV: 90% versus 80%; left inferior PV: 80% versus 78%; right superior PV: 81% versus 80%, and right inferior PV: 76% versus 73%. For each reconnected PV, 34% of ipsilateral PVs were also reconnected after CRYO compared with 64% after RF (RR: 0.54; 95% CI: 0.32-0.90; p = .01). After RF, gaps were clustered by the carina and adjacent segments, whereas they were more heterogeneously distributed after CRYO.

CONCLUSION

Although RF and CRYO produce similar proportions of durably isolated PVs, gap locations appear to develop in procedure-specific patterns. After RF, ipsilateral PV reconduction is more frequent and gap sites cluster by the carina, suggesting that this region should be selectively ablated for more durable PVI.

Short- and long-term risk of atrial fibrillation recurrence after first time ablation according to body mass index: a nationwide Danish cohort study

AIMS

Overweight is associated with increased risk of atrial fibrillation (AF), but the impact of overweight and AF recurrence after ablation is less clear. Despite this, an increasing number of AF ablations are carried out in overweight patients. We investigated the impact of body mass index (BMI) on AF recurrence rates after ablation.

METHODS AND RESULTS

Through Danish nationwide registers, all patients undergoing first-time AF ablation between 2010 and 2018 were identified. Exposure of interest was BMI. The primary outcome was recurrent AF, defined from either any usage of antiarrhythmic medication, AF hospitalization, cardioversion, or re-ablation. A total of 9188 patients were included. Median age and interquartile range was 64 (60-75) in the normal-weight group and 60 (53-66) in the morbidly obese. There was an increase in comorbidity burden with increasing BMI, including a higher prevalence of heart failure, chronic obstructive pulmonary disease, diabetes, and hypertension. At 1- and 5-year follow ups, recurrence rates of AF increased incrementally by BMI categories. The hazard ratios and 95% confidence intervals of recurrent AF after ablation were 1.15 (1.07-1.23), 1.18 (1.09-1.28), and 1.26 (1.13-1.41) in overweight, obese, and morbidly obese, respectively, compared with normal-weight patients. Procedure duration and X-ray dose exposure also increased with increasing BMI.

CONCLUSION

Following AF ablation, recurrence rates of AF increased incrementally with increasing BMI. Therefore, aggressive weight management pre ablation in overweight patients could potentially provide substantial benefits and improve short- and long-term outcomes after ablation.

Posterior wall isolation in persistent atrial fibrillation. Long-term outcomes of a repeat procedure strategy

BACKGROUND

Posterior wall isolation (PWI) added to pulmonary vein isolation (PVI) is increasingly used in ablation for persistent atrial fibrillation (PeAF) despite limited evidence of clinical benefit. We investigated the 5-year outcomes of a PVI + PWI ablation strategy with mandatory repeat procedures in PeAF.

METHODS

Twenty-four patients with PeAF participated in this single-arm prospective study and underwent radiofrequency ablation (RFA) with wide area circumferential ablation (WACA), roof, and inferior lines for PVI + PWI which was reinforced if required during mandated repeat procedures after 6 months. Then, patients were followed for 60 months using continuous heart rhythm monitoring by implanted cardiac monitors (ICM) and atrial fibrillation effect on quality-of-life scoring (AFEQT; range: 20-100 points) for the initial 30 months.

RESULTS

ICM-verified cumulated AF recurrence was 54% after 30 months but the ensuing AF burden was only median 0‰ [0 to 4.8‰] overall and 1‰ [0 to 8 ‰] among patients with any recurrence. AFEQT scores increased from baseline 60 points [48 to 72] to 93 points [84 to 96] at repeat procedures P < 0.0001 and further to 96 points [93 to 99] P = 0.03 after 30 months. After 60 months, at least one episode of AF had been documented in 63% and two patients (8%) were in permanent AF.

CONCLUSION

Reinforced PVI + PWI was associated with low long-term AF burden and corresponding improvements in quality-of-life. Reinforced (or durable) PVI + PWI appears to be a promising strategy to treat PeAF.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT05045131.

Dual-chamber paced patients without high-degree AV block at baseline are at higher risk of atrial arrhythmias when inappropriately paced in the right ventricle: a sub-analysis of the EMERALD study

Background/Introduction

Unnecessary right ventricular pacing (RVP) can have deleterious effects including an increased risk of atrial arrhythmia (AA) and heart failure during follow-up (FU) in dual-chamber (DR) paced patients. While previous studies have shown that these increased risks occur with RVP&gt;40%, the EMERALD Study demonstrated an increased risk for RVP&gt;1%. Few data exist on the interaction between the amount of RVP and the presence/absence of high-degree atrio-ventricular block (AVB) as a pacing indication at baseline.

Purpose

The EMERALD (AssEssment of CoMorbiditiEs & Atrial ArRhythmiA Burden In DuaL-Chamber PaceD Patients) Study was a real-world registry designed to assess the impact of RVP burden on the risk of developing persistent/permanent AA (Pers-AA) over 2-year FU. The primary endpoint was the difference in Pers-AA in subjects with high (&gt;40%) and low (&lt;40%) RVP. This sub-analysis aimed to identify the interaction between RVP and the presence/absence of high-degree AVB at baseline in relation to the incidence of Pers-AA.

Methods

EMERALD was a non-interventional, prospective, multi-center registry conducted at 186 centers in 12 countries. Enrolled subjects were implanted with a DR pacemaker according to ESC or ACC/AHA/HRS guidelines. Subjects were excluded if they had a history of Pers-AA. Devices could be implanted as de-novo, replacement or upgrade therapy. Programming was left to the investigators' discretion. Subjects were followed for at least 24 months. Pers-AA was defined as: &gt;22 h/day of AA for &gt;7 consecutive days; Pers-AA diagnosed during any FU visit; AA-related ablation or cardioversion carried out in the FU period. We compared the incidence of Pers-AA between subjects with (n=1529) and without (n=1948) high-degree AVB as a baseline pacing indication.

Results

Eligible FU data were available for n=3477 subjects. The overall population was nearly evenly split - High RVP (47.7%) and Low RVP (52.3%). In the High RVP group, 11.7% experienced at least one Pers-AA episode versus 9.1% in the Low RVP group (p=0.006). In this sub-analysis, the prevalence of RVP&gt;40% was higher in patients with high-degree AVB at baseline (74% vs 26%). Although the incidence of Pers-AA was similar in the group with high-degree AVB at baseline (High RVP 8.7% vs Low RVP 7.4%), in the group without high-degree AVB at baseline, those with High RVP developed a significantly higher incidence of Pers-AA (High RVP 18.2% vs Low RVP 9.5%, p value for interaction 0.0275; Figure 1). An analysis with a newly identified RVP threshold of 1% confirmed a high incidence of Pers-AA only in the group without high-degree AVB at baseline (18% vs 3.5%, p value for interaction 0.2265; Figure 2).

Conclusions

The baseline pacing indication sub-analysis of the EMERALD Study shows that patients without high-degree AVB as a baseline indication are at highest risk of Pers-AA. Efforts should be made to avoid any unnecessary RVP in this subgroup of patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): MicroPort CRM (Clamart, France)

Long-term risk of replacement of cardiovascular implantable electronic devices following external cardioversion

Introduction

External cardioversion (ECV) with transthoracic shock is a recommended and important part of the rhythm control strategy regardless of cardiovascular implantable electronic devices (CIED). Studies and case reports have demonstrated rare, but serious CIED malfunctions related to the ECV procedure. However, follow-up data on contemporary CIEDs undergoing ECV procedures are limited. The aim of this study is to investigate the long-term risk of generator replacements following an ECV procedure.

Methods

All CIED implants and surgical re-interventions in Denmark were identified in the Danish Pacemaker and ICD Register from January 2005 to April 2021. The ECV procedures were identified in the Danish National Patient Registry from January 2010 to February 2019. For each patient undergoing ECV, five matched (age, sex, and type of CIED) controls without previous ECV were identified. Time to generator replacement was estimated using competing risk analyses, with death, extraction and up-/down-grade being competing events. Risks were estimated by the pseudo-observation method.

Results

We identified in total 3,924 ECV-events in 2,610 CIED patients with 74.4% male. Mean age of patients at first ECV-procedure were 68.6±11.7 years, and median implant time was 1.5 year. The type of CIED included 50% of pacemakers, 28% of Implantable Cardioverter Defibrillators, and 22% of Cardiac Resynchronization Therapy-systems. During the first 5 years of follow-up, 451 (17.3%) of the shock-exposed devices were replaced vs. 2,000 (15.2%) of the unexposed devices. The relative risks (RR) of device replacement were 1.43 (95% CI: 0.5; 2.4) after 12 months, 1.44 (95% CI: 0.1; 2.8) after 24 months, and −0.53 (95% CI: −2.8; 1.7) after 5 years. The cumulated incidence of first endpoint: Replacement, death, extraction, and up-/down-grade are illustrated in Figure 1. A larger proportion of patients died in the shock-exposed group with n=427 (16.4%) compared to n=1,588 (12.2%) in the unexposed group during 5-years of follow-up with RR=3.2 (95% CI: 1.2; 5.3) of dead before other events.

Conclusion

Contemporary CIEDs do not indicate different risk of generator replacement following external cardioversion with transthoracic shocks. Shock-exposed device patients were more prone for extraction and death.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): This is work was financed by Department of Cardiology, Aalborg University Hospital and supported by Karl G. Andersen foundation.

A-19 Distress Predicts Poorer Cognitive Performance At Post-Injury In Concussed Athletes

Purpose: This study evaluated the consistency between athletes’ self-reported cognitive symptoms and cognitive test performance. Methods: The sample included 784 Canadian Football League athletes who underwent standardized cognitive testing with cognitive testing (ImPACT) and the Brief Symptom Inventory (BSI-18) at baseline. Over 2 consecutive seasons, 46 players were diagnosed with concussions following assessment with team physicians within 48 hours; 10 were eliminated due to missing data. Five cognitive symptoms (feeling slowed down, feeling in a fog, not feeling right, difficulties concentration, difficulties with memory) were used to create a composite score (Cog). The Cog index, the depression, anxiety, total index scores from the BSI, and the 5 ImPACT cognitive domains were correlated at baseline and post-injury. History of learning disabilities, ADHD, psychiatric diagnosis, and history of concussion were co-variates. Results: There were no significant correlations between Cog, depression, anxiety or total BSI scores and the ImPACT cognitive domains at baseline. At post injury there were no significant correlations between Cog or ImPACT index scores. In contrast, significant negative correlations were found between BSI Anxiety and verbal memory (r = 0.67, p &lt; 0.01), visual memory (r = 0.68, p &lt; 0.01), and visual-motor processing speed (r = 0.48, p &lt; 0.05). In addition, there were significant negative correlations between the BSI total score and visual memory (r = 0.51, p &lt; 0.05) and reaction time (r = 0.55, p &lt; 0.05). Conclusions: Self-reported cognitive difficulties do not correlate with poorer cognitive outcomes in our sample of professional football players. However, distress at post-injury was significantly correlated to performance, suggesting psychological variables may play a role in cognitive functioning.

A-37 Ocular Motor Impairments in Concussion Professional Football Players

Purpose: The purpose of this study was to examine baseline and post-concussion injury characteristics of ocular eye movements using the Sync Think visual eye tracking apparatus in professional football players in the Canadian Football League (CFL). Methods: The visual tracking testing protocol uses an integrated stimulus presentation-eye tracking apparatus (EyeLink CL; SR Research, Ontario, Canada) with which eye movements were recorded at 500 Hz using infrared video-oculography. The standard deviation of radial errors (SDRE) and tangential errors (SDTE) were used to determine poor visual tracking. Participants were (n = 748) rostered players in the Canadian Football League. All participants completed assessments at baseline. Sixteen players completed post-concussion assessments and 98 players completed post-exertional assessments during the 2021 season to evaluate the impact of physical exertion on ocular movement metrics. Results: Participants with diagnosed concussions (n = 16+) demonstrated significantly poorer performance on measures of both gaze stability and smooth pursuit (p &lt; 0.001). The poorer results were correlated with significantly higher subjective ratings of dizziness (p &lt; 0.01) and fogginess (p &lt; 0.001). In contrast, healthy participants who completed the same ocular motor assessments demonstrated no significant differences compared to baseline test performance. Conclusions: Findings suggest that subtle differences in oculomotor functioning arise from sport concussion in professional football players. Further research with larger sample sizes and correlation with other cognitive and physical outcomes is warranted.

A-12 Mental Health Outcomes for CFL Athletes with ADHD

Purpose: Current research suggests that athletes with Attention Deficit Hyperactivity Disorder (ADHD) are at risk for poorer outcomes arising from sport related concussions (SRC). There is limited research related evaluating mental health outcomes in athletes diagnosed with ADHD. The purpose of the study is to evaluate mental health outcomes among Canadian Football League (CFL) athletes with (ADHD) and to measure outcomes based upon a history of concussion. Methods: Professional football players from the CFL (n = 784) were administered a baseline mental health measure, the Health-Related Quality of Life (HRQL), as a component of pre-season evaluations as part of a larger cohort study (Active Rehabilitation). Diagnosis of ADHD was the independent variable and HRQL index scores measuring physical functioning, depression, cognitive functioning, were dependent variables. A second analysis compared ADHD athletes with no history of concussion to those with a history of concussion on the HRQL indexes. Results: Participants diagnosed with ADHD (n = 80) had statistically significant differences on the Physical Functioning (t(782) = −3.359, p &lt; 0.001), Depression ((t(782) = −2.820, p = 0.002) and Cognitive (t(782) = −3.570, p &lt; 0.001) domains of the HRQL, compared to athletes without ADHD. Among the athletes who are diagnosed with ADHD, no mental health differences were found between those who have at least one concussion and those who do not. Conclusions: This study did not find a significant effect of concussion on mental health outcomes in participants with ADHD. However, athletes with ADHD present with higher mental health symptoms which may merit closer monitoring.

POS0423 CYCLIC CITRULLINATED PEPTIDE APTAMER TREATMENT ATTENUATES COLLAGEN INDUCED ARTHRITIS

Background

Anti-citrullinated peptide antibodies (ACPA) appear 10–15 years before the diagnosis of rheumatoid arthritis (RA) and are associated with a more severe disease course. In previous work, we rationally designed and screened ACPA-binding peptide aptamer sequences in silico and constructed a nanoparticle with chitosan and hyaluronic acid(1). A developmental stage version of this nanoparticle was able to reduce disease activity in the collagen-induced arthritis (CIA) and the serum transfer arthritis mouse models (2).

Objectives

Here, we investigated the effect and potential toxicity of three different versions of the aptamer nanoparticle (loading of 20%, 10% and 5% aptamer, respectively) in the CIA rat model.

Methods

Wistar rats (males and females) were given a single intravenous dose (100 mg/kilo) of type II collagen in PBS in the tail vein. The dosing was repeated three times with one day interval, followed by blood sample collection at day 7 after the initial collagen injection. To evaluate route of administration and dosing, we injected a single intravenous and subcutaneous dose (2.5 mg/kg) of aptamer-nanoparticles (A/N ratio 20%) in PBS in the tail vein/abdomen, and plasma concentration−time profiles were followed for 2 days after dosing with weekly blood sampling. To evaluate organ uptake, rats were given a single intravenous and subcutaneous dose (2.5 mg/kg) of aptamer-nanoparticles (A/N ratio 20%) in PBS in the tail vein/abdomen. The procedure was repeated after 24 hours. Blood and urine samples were taken once a week. A group of 10 animals was sacrificed every week over a three-week period, and the organs were processed. To examine efficacy, rats were given a single subcutaneous dose (2.5 mg/kilo) of aptamer-nanoparticles and nanoparticle controls without aptamer or PBS alone in the abdomen. The procedure was repeated once a week over a course of three weeks. Weight, joint measurement, blood, and urine samples were taken once a week. Paw swelling was measured on a weekly basis. In the plasma samples we measured CPEP2 and anti-collagen II by enzyme linked immunosorbent assay (ELISA).

Results

Using a rather high dose of collagen (100 mg/kilo) via an intravenous administration route, ACPA was measurable in all CIA rats with rapid development of RA in 82% of the included animals. Intravenous administration resulted in an immediate high plasma concentration post injection, which decreased rapidly to low levels. The s.c. administration route gave a steady, long-term aptamer release with a maximum availability 8 hours post-injection. After three aptamer-nanoparticle doses (2.5 mg/kg; either 20%, 10% or 5% aptamer), we observed a dose-dependent reduction in swollen joint count for the aptamer-nanoparticle treated groups (10 rats in each group) compared with the healthy control group (10 rats) (P-value = 2,1E-6). We observed decreased ACPA IgG levels in the rats treated with aptamer-nanoparticle. The decrease in ACPA levels correlated with the aptamer-nanoparticle having higher loading. Anti-collagen II IgG levels slightly increased towards the end of the study.

Conclusion

We developed and tested a novel peptide aptamer-based drug candidate for seropositive rheumatoid arthritis in CIA rats. Over a 3-week course of treatment with subcutaneous administration of aptamer-nanoparticles, joint swelling was decreased during treatment, and completely reversed at the end of the observation period. The reduction of joint swelling was associated with decreased levels of ACPA in the blood.

References

[1]Khatri S, Hansen J, Mendes AC, et al. Citrullinated Peptide Epitope Targets Therapeutic Nanoparticles to Human Neutrophils. Bioconjug Chem. 2019;30(10):2584-2593. doi:10.1021/acs.bioconjchem.9b00518

[2]Khatri S, Hansen J, Clausen MH, et al. LB0002 A FIRST IN CLASS THERAPEUTIC NANOPARTICLE FOR SPECIFIC TARGETING OF ANTI-CITRULLINATED PROTEIN ANTIBODY AMELIORATES SERUM TRANSFER AND COLLAGEN INDUCED ARTHRITIS. Annals of the Rheumatic Diseases 2020;79:212.

Disclosure of Interests

Sangita Khatri: None declared, Jonas Hansen: None declared, Nadia Pedersen: None declared, Sanne Gram-Nielsen: None declared, Ana Mendes: None declared, Ioannis Chronakis: None declared, Ulrik Keiding: None declared, Bence Réthi: None declared, Mads Hartvig Clausen Shareholder of: affiliated with IBIO TECH ApS, Tue Wenzel Kragstrup Shareholder of: affiliated with IBIO TECH ApS, Speakers bureau: TWK received speaking fees from Pfizer, Bristol-Myers Squibb, Eli Lilly, Novartis, UCB, and Abbvie., Consultant of: Consultancy fees from Bristol-Myers Squibb and Gilead, Grant/research support from: Received research grant from Gilead, Kira Astakhova Shareholder of: KA is affiliated with iBio tech.

Multi-national survey on the methods, efficacy, and safety on the post-approval clinical use of pulsed field ablation (MANIFEST-PF)

AIMS

Pulsed field ablation (PFA) is a novel atrial fibrillation (AF) ablation modality that has demonstrated preferential tissue ablation, including no oesophageal damage, in first-in-human clinical trials. In the MANIFEST-PF survey, we investigated the 'real world' performance of the only approved PFA catheter, including acute effectiveness and safety-in particular, rare oesophageal effects and other unforeseen PFA-related complications.

METHODS AND RESULTS

This retrospective survey included all 24 clinical centres using the pentaspline PFA catheter after regulatory approval. Institution-level data were obtained on patient characteristics, procedure parameters, acute efficacy, and adverse events. With an average of 73 patients treated per centre (range 7-291), full cohort included 1758 patients: mean age 61.6 years (range 19-92), female 34%, first-time ablation 94%, paroxysmal/persistent AF 58/35%. Most procedures employed deep sedation without intubation (82.1%), and 15.1% were discharged same day. Pulmonary vein isolation (PVI) was successful in 99.9% (range 98.9-100%). Procedure time was 65 min (38-215). There were no oesophageal complications or phrenic nerve injuries persisting past hospital discharge. Major complications (1.6%) were pericardial tamponade (0.97%) and stroke (0.4%); one stroke resulted in death (0.06%). Minor complications (3.9%) were primarily vascular (3.3%), but also included transient phrenic nerve paresis (0.46%), and TIA (0.11%). Rare complications included coronary artery spasm, haemoptysis, and dry cough persistent for 6 weeks (0.06% each).

CONCLUSION

In a large cohort of unselected patients, PFA was efficacious for PVI, and expressed a safety profile consistent with preferential tissue ablation. However, the frequency of 'generic' catheter complications (tamponade, stroke) underscores the need for improvement.

External cardioversion of atrial fibrillation and flutter in patients with cardiac implantable electrical devices

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atrial tachyarrhythmias are often treated with external cardioversion (ECV) with direct current shocks in patients with potentially electrically sensitive cardiovascular implantable electronic devices (CIED). Long-term follow-up data on contemporary pacemakers and implantable cardioverter defibrillators (ICD) undergoing ECV is sparsely described. This study investigated shock-related complications and impact on CIEDs.

Methods

All ECV procedures of atrial fibrillation and flutter from 2010 to 2020 in patients with CIED performed at a tertiary hospital (Denmark) were identified in the Danish National Patient Registry. Data on device interrogation before and after ECV and procedure-related complications were retrieved retrospectively by review of medical records.

Results

We analysed 664 ECV-events performed in 362 CIEDs, median implant time 1.5 year. Mean age of patients at first ECV-event were 69.4±9.7 years and 72.2% were men. We identified two cases of major programming changes and two cases of premature battery depletion (≤3 years after generator implant) following ECV. Minor shock-related device changes were found for impedances, atrial sensing values and pacing thresholds of right ventricle lead. In two cases increased pacing threshold of right ventricle leads following ECV triggered exit-blocks after few months. No patients died due to shock-related device dysfunctions.

Conclusion

Following external cardioversion with transthoracic direct current shocks, sporadic (&lt;1%) but potentially critical changes in device function were identified in patients with contemporary pacemakers and implantable cardioverter-defibrillators. The present study suggests that routine post-cardioversion device interrogation is imperative for patient safety.

Recurrence rates of atrial fibrillation ablation according to body mass Index, a nationwide, registry-based danish study

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Novo Nordisk supported the project.

Background

The proportion of people with obesity is rapidly rising, and the number of overweight patients undergoing ablation for atrial fibrillation (AF) is also increasing. The link between body mass index (BMI), and AF prevalence is well-established but the impact of BMI on the risk of recurrent AF after ablation is less elucidated. Therefore, data pertaining to recurrence rates of ablations according to BMI in large, unselected cohorts of patients is still warranted.

Purpose

To examine the risk of recurrent AF after AF ablation by BMI.

Method

Using Danish nationwide registries, all Danish patients above 18 years who underwent first-time AF ablation from January 1st 2010 to December 31st 2018 were identified and included at the date of ablation. The patients were categorized by BMI; underweight: &lt; 18.5 kg/m2; normal weight: 18.5-24 kg/m2; overweight 25-29 kg/m2; obese 30-34 kg/m2; morbidly obese &gt; 34 kg/m2. Recurrent AF was defined using a composite endpoint comprising claimed prescriptions of anti-arrhythmic drugs, hospital admissions due to AF, re-ablation, or electrical cardioversions. The cumulative incidence of recurrent AF by BMI at 1- and 5-year follow-up after a blanking period of 90 days, was estimated using the Aalen-Johansen estimator, takin death as competing risk in to account. The relative rates of recurrent AF by BMI were examined using Cox models adjusted for sex, age, procedure-year, heart failure, ischemic heart disease, chronic obstructive pulmonary disease, chronic kidney disease, hypertension, and diabetes.

Results

The study cohort consisted of 9,229 patients. Median age [IQR] decreased from 64 [60, 75] in the normal weight group to 60 [53, 66] in the morbidly obese. The number of patients with a CHA2DS2-VASc score of 2 or more increased from 48% in normal-weight to 65% in morbidly obese. Use of amiodarone increased by BMI category, while the use of Class 1C anti-arrhythmic medication remained stable.

Figures 1 and 2 show the 1- and 5-year cumulative incidence of recurrent AF, Hazard Ratios (HR), and 95% Confidence Intervals (CI 95%) stratified by BMI categories and depict that the risk of recurrent AF increased incrementally and significantly in overweight groups compared to normal weight patients, both in 1- and 5-year follow-up. Underweight patients demonstrated non-significantly increased risk of recurrent AF, both in 1- and 5-year follow-up.

Conclusion

In this large nationwide study examining recurrent AF post AF ablation, we found that recurrence rates of AF increased incrementally according to BMI, both in short- and long-term follow-up. Therefore, aggressive weight management in overweight patients could potentially provide substantial benefits and improve short- and long-term outcomes after ablation.

Computational design of mechanically coupled axle-rotor protein assemblies

Natural molecular machines contain protein components that undergo motion relative to each other. Designing such mechanically constrained nanoscale protein architectures with internal degrees of freedom is an outstanding challenge for computational protein design. Here we explore the de novo construction of protein machinery from designed axle and rotor components with internal cyclic or dihedral symmetry. We find that the axle-rotor systems assemble in vitro and in vivo as designed. Using cryo-electron microscopy, we find that these systems populate conformationally variable relative orientations reflecting the symmetry of the coupled components and the computationally designed interface energy landscape. These mechanical systems with internal degrees of freedom are a step toward the design of genetically encodable nanomachines.

Left atrial contractile strain predicts recurrence of atrial tachyarrhythmia after catheter ablation

BACKGROUND

Despite improvement in treatment strategies of atrial fibrillation (AF), a considerable number of patients still experience recurrence of atrial tachyarrhythmia (ATA) following catheter ablation (CA). This study aimed to investigate the prognostic value of left atrial (LA) deformation analysis in a large group of patients undergoing CA for AF.

METHODS

This study included 678 patients with AF. Echocardiography including two-dimensional speckle tracking echocardiography (2DSTE) was performed in all patients prior to CA. Logistic regression analysis was used to assess the association between ATA recurrence and LA strain during reservoir phase (LASr), LA strain during contraction phase (LASct), and LA strain during conduit phase (LAScd).

RESULTS

During one-year follow-up, 274 (40%) experienced ATA recurrence. Median age of the included study population was 63.2 years (IQR: 55.5, 69.5) and 485 (72%) were male. Patients with recurrence had lower LASr (22.6% vs. 25.1%, p = 0.001) and LASct (10.7% vs. 12.4%, p < 0.001). No difference in LAScd was observed. After adjusting for potential clinical and echocardiographic confounders LASr (OR = 1.04, CI95% [1.01; 1.07], p = 0.015, per 1% decrease) and LASct (OR = 1.06, CI95% [1.02; 1.11], p = 0.007, per 1% decrease) remained independent predictors of recurrence. However, in patients with a normal-sized LA (LA volume index<34 mL/m²), only LASct remained an independent predictor of recurrence (OR = 1.07, CI95% [1.01; 1.12], p = 0.012, per 1% decrease).

CONCLUSION

In patients undergoing CA for AF, LA deformation analysis by 2DSTE could be of use in risk stratification in clinical practice regarding ATA recurrence, even in patients with a normal-sized LA.

MRI-Detected Brain Lesions and Cognitive Function in Atrial Fibrillation Patients Undergoing Left Atrial Catheter Ablation in the Randomized AXAFA-AFNET 5 Trial

Background: To assess the prevalence of magnetic resonance imaging (MRI) detected ischemic brain lesions and their association with cognitive function 3-months after first-time ablation using continuous oral anticoagulation in patients with paroxysmal atrial fibrillation (AF). Methods: Pre-specified analysis of the Anticoagulation using the direct factor Xa inhibitor apixaban during Atrial Fibrillation catheter Ablation: Comparison to vitamin K antagonist therapy (AXAFA-AFNET 5) trial, randomizing 674 patients with AF 1:1 to uninterrupted apixaban or vitamin K-antagonist therapy prior to first-time ablation. Brain MRI using fluid-attenuated inversion recovery (FLAIR) and high-resolution diffusion weighted imaging (hrDWI) was obtained within 3-48 hours after AF ablation in all eligible patients enrolled in 25 study centers in Europe and the United States. Patients underwent cognitive assessment 3-6 weeks before ablation and 3 months after ablation using the Montreal Cognitive Assessment (MoCA). Results: In 84 (26.1%) of 321 patients with analyzable MRI, hrDWI detected at least one acute brain lesion, including 44 (27.2%) apixaban and 40 (24.8%) vitamin K antagonist treated patients (p=0.675). Median MoCA score was similar in patients with or without acute brain lesions at 3-months after ablation (28 (IQR 26-29) vs. 28 (IQR 26-29); p=0.948). FLAIR-detected cerebral chronic white matter damage (defined as Wahlund score ≥4 points) was present in 130 (40.5%) patients and associated with lower median MoCA scores before ablation (27 (24-28) vs. 27 (IQR 25-29); p=0.026) and 3-months after ablation (27 (IQR 25-29) vs. 28 (IQR 26-29); p=0.011). Adjusted for age and gender, this association was no longer significant. Age was associated with lower MoCA scores before ablation (RR 1.02 per 10 years (95%CI 1.01-1.03)) and 3-months after ablation (RR 1.02 per 10 years (95%CI 1.01-1.03)). Conclusions: Brain MRI-detected chronic white matter damage as well as acute ischemic lesions were frequently found after first-time ablation for paroxysmal AF using uninterrupted oral anticoagulation. hrDWI-detected acute ischemic brain lesions were not associated with cognitive function at 3-months after ablation. Lower MoCA scores before and after ablation were associated with old age only, highlighting the safety of AF ablation on uninterrupted oral anticoagulation.

Protocol for detecting unrecognized sleep apnea in patients with atrial fibrillation by a home-monitoring device: the DAN-APNO study

BACKGROUND

Determining the presence of modifiable risk factors for atrial fibrillation (AF), such as sleep apnea is of clinical importance due to the potential impact targeting these risk factors can have on the progression and burden of AF. Using new digital-based technology is a promising solution to the underreporting of sleep apnea highlighted by academical societies in recent years. The aim of this study is to report the prevalence and severity of sleep apnea in patients with AF and, secondarily, assess the accuracy and feasibility of a new home-screening device for sleep apnea (NightOwl™ by Ectosense).

METHODS

DAN-APNO is a cross-sectional study at the Department of Cardiology, Herlev-Gentofte Hospital recruiting patients with AF referred to anticoagulation initiation aged 18 to 90 years without known sleep apnea. At least 150 patients will be recruited and undergo medical history, clinical evaluation, several sleep-apnea questionnaires, and a sleep-recording evaluation for four nights with sleep apnea home-monitoring device NightOwl™. Additionally, the first 20 participants and participants with moderate-severe sleep apnea by screening are referred to cardio-respiratory monitoring (CRM). This clinical evaluation allows the comparison of standard evaluation method and the NightOwl™. Clinical measures include Apnea-Hypopnea Index (AHI), Oxygen Desaturation Index (ODI), pulse rate, as well as questionaries about sleep apnea assessment and the clinical feasibility of the NightOwl™ device. Main outcomes comprise analysis of the prevalence and severity of sleep apnea, and clinical and demographic predictors of moderate and severe sleep apnea. In addition, correlation analyses for accuracy measures between CRM and NightOwl™ will be conducted along with patient ease-of-use and satisfaction questionnaires.

DISCUSSION

This study is limited by selection bias; only patients with atrial fibrillation from anticoagulation clinic is asked to participate, which could limit the generalizability of our results. However, this study aims to test whether a miniaturized simple home-monitoring device for detecting sleep apnea in patients with AF potentially can evaluate sleep apnea more conveniently and easier. Trial Registration The study is registered the 18-02-2021 at clinicaltrials.gov with registration number: NCT04760002.

What is a covid dashboard?

 

Public Health Reporting has a long history (text here suddenly missing!)There is a long tradition of Public Health Reporting to support knowledge during public health crises. The Covid-19 pandemic has seen the unprecedented rapid demand for Public Health Reporting. The size, speed and scale of the pandemic led to governments, public health professionals, the media and citizens asking for up-to-date, accurate and accessible information and intelligence. One way that these demands were answered were through the creation and publication of Covid-19 dashboards to communicate to diverse audiences. Health Information Professionals were required to make significant decisions quickly. Which indicators to select? Which audiences to develop dashboards for? Which technologies to deploy? Decisions that would normally take a considerable length of time were abbreviated. There were no international standards and a variability of requirements for different commissioners of dashboards. Furthermore the public spotlight and ‘democratisation' of health information created additional pressure and a lack of situational control. Some of the choices made will have a consequential impact for shared Health Service and Population Health Research as the pandemic continues.

 

The purpose of this presentation is to

Discuss the need for rapid health reporting as a result of the Covid-19 pandemic

Examine some of the choices faced by health information professionals in creating and sustaining public Covid-19 dashboards during the pandemic.

Illustrate a variety of solutions that emerged internationally that were broadly trying to address the same need.

Genetic Variant Score and Arrhythmogenic Right Ventricular Cardiomyopathy Phenotype in Plakophilin-2 Mutation Carriers

INTRODUCTION

Whether detailed genetic information contributes to risk stratification of patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) remains uncertain. Pathogenic genetic variants in some genes seem to carry a higher risk for arrhythmia and earlier disease onset than others, but comparisons between variants in the same gene have not been done. Combined Annotation Dependent Depletion (CADD) score is a bioinformatics tool that measures the pathogenicity of each genetic variant. We hypothesized that a higher CADD score is associated with arrhythmic events and earlier age at ARVC manifestations in individuals carrying pathogenic or likely pathogenic genetic variants in plakophilin-2 (PKP2).

METHODS

CADD scores were calculated using the data from pooled Scandinavian and North American ARVC cohorts, and their association with cardiac events defined as ventricular tachycardia/ventricular fibrillation (VT/VF) or syncope and age at definite ARVC diagnosis were assessed.

RESULTS

In total, 33 unique genetic variants were reported in 179 patients (90 males, 71 probands, 96 with definite ARVC diagnosis at a median age of 35 years). Cardiac events were reported in 76 individuals (43%), of whom 53 had sustained VT/VF (35%). The CADD score was neither associated with age at cardiac events (HR 1.002, 95% CI: 0.953-1.054, p = 0.933) nor with age at definite ARVC diagnosis (HR 0.992, 95% CI: 0.947-1.039, p = 0.731).

CONCLUSION

No correlation was found between CADD scores and clinical manifestations of ARVC, indicating that the score has no additional risk stratification value among carriers of pathogenic or likely pathogenic PKP2 genetic variants.

Radiofrequency Versus Cryoballoon Catheter Ablation for Paroxysmal Atrial Fibrillation: Durability of Pulmonary Vein Isolation and Effect on Atrial Fibrillation Burden: The RACE-AF Randomized Controlled Trial

Supplemental Digital Content is available in the text.

Background:

Recurrent paroxysmal atrial fibrillation (AF) after catheter ablation is presumably caused by failure to achieve durable pulmonary vein isolation (PVI). The primary methods of PVI are radiofrequency catheter ablation (RF) and cryoballoon catheter ablation (CRYO), but these methods have not been directly compared with respect to PVI durability and the effect thereof on AF burden (% of time in AF).

Methods:

Accordingly, we performed a randomized trial including 98 patients (68% male, 61 [55–67] years) with paroxysmal AF assigned 1:1 to PVI by contact-force sensing, irrigated radiofrequency catheter, or second-generation cryoballoon catheter. Implantable cardiac monitors were inserted ≥1 month before PVI for assessment of AF burden and recurrence, and all patients, irrespective of AF recurrence, underwent a second procedure 4 to 6 months after PVI to determine PVI durability.

Results:

In the second procedure, 152 out of 199 (76%) pulmonary veins (PVs) were found durably isolated after RF and 161 out of 200 (81%) after CRYO (P=0.32), corresponding to durable isolation of all veins in 47% of patients in both groups (P=1.0). Median AF burden before PVI was 5.4% (interquartile range, 0.5%–13.0%) versus 4.0% (0.6%–18.1%), RF versus CRYO (P=0.71), and reduced to 0.0% (0.0%–0.1%) and 0.0% (0.0%–0.5%), respectively (P=0.58)—a reduction of 99.9% (92.9%–100.0%) and 99.3% (85.9%–100.0%; P=0.36). AF burden after PVI significantly correlated to the number of durably isolated PVs (P<0.01), but 9 out of 45 (20%) patients with durable isolation of all veins had recurrence of AF within 4 to 6 months after PVI (excluding a 3-month blanking period).

Conclusions:

PVI by RF and CRYO produce similar moderate to high PVI durability. Both treatments lead to marked reductions in AF burden, which is related to the number of durably isolated PVs. However, for one-fifth of paroxysmal AF patients, complete and durable PVI was not sufficient to prevent even short-term AF recurrence.

Registration:

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03805555.

Standardized training in the rating of the six-item positive and negative syndrome scale (PANSS-6)

Introduction

The six-item Positive And Negative Syndrome Scale (PANSS-6) is short psychometric valid scale quantifying the severity of core schizophrenia symptoms. Using PANSS-6 to guide treatment decision-making requires that staff members’ ratings are valid and reliable.

Objectives

The objective of the study was to evaluate whether such valid and reliable PANSS-6 ratings can be obtained through a video-based training program.

Methods

One-hundred-and-four staff members from Aarhus University Hospital - Psychiatry, Denmark participated in the training. Participants conducted baseline PANSS-6 ratings based on a video of a patient being interviewed using the Simplified Positive And Negative Symptoms interview (SNAPSI). Subsequently, a theoretical introduction video was displayed followed by five SNAPSI patient interviews. After each SNAPSI video, individual ratings were performed before a video providing the gold standard scores was displayed. The validity of ratings was estimated by calculating the proportion of participants not deviating from the gold standard scores with >2 points on individual items or >6 points on the PANSS-6 total score. Reliability was evaluated after each step in the training by means of Gwet’s Agreement Coefficient (Gwet).

Results

By the end of the training, 72% of the participants rated within the acceptable deviations of the gold standard, ranging from 60% (nurses) to 91% (medical doctors/psychologists). The reliability improved (Gwet baseline vs. endpoint) for all PANSS-6 items, except for Blunted affect.

Conclusions

The majority of the staff members conducted valid PANSS-6 ratings after a brief standardized training program, supporting the implementation of PANSS-6 in clinical settings to facilitate measurement-based care.

Conflict of interest

Dr. Opler is a full-time employee of MedAvante-ProPhase Inc. Dr. Correll has been a consultant and/or advisor to or have received honoraria from: Acadia, Alkermes, Allergan, Angelini, Axsome, Gedeon Richter, Gerson Lehrman Group, Indivior, IntraCellular T

Left atrial function assessed by speckle tracking echocardiography predicts atrial fibrillation burden after catheter ablation independently of reconduction: a RACE-AF echocardiographic sub-study

Funding Acknowledgements

Type of funding sources: None.

Background

Left atrial (LA) function assessed by 2D speckle tracking echocardiography (STE) has demonstrated to be a useful predictor of recurrence of atrial fibrillation (AF) following catheter ablation (CA). Pulmonary vein reconduction (PVR) is one of the most important causes of recurrent paroxysmal AF (PAF) after ablation. The purpose of this study was to evaluate the association between AF burden (% of time in AF) following CA and LA strain measurements independently of PVR.

Methods

This prospective study included 66 patients with PAF who underwent CA (mean age 60 ± 8 years, 65% male). STE was performed during sinus rhythm prior to CA. AF burden was recorded by continuous rhythm monitoring using implantable loop recorders during a follow-up period of 4-6 months, excluding a blanking period of 3 months. After follow-up, all patients underwent an invasive assessment of pulmonary vein isolation to test for PVR. Multivariable linear regression analysis was used to assess the association between AF burden and peak atrial longitudinal reservoir strain (PALS), peak atrial contraction strain (PACS) and peak atrial conduit strain (PCS).

Results

Prior to CA, median AF burden was 3.8% (IQR: 0.5, 17). During follow-up, 37 patients (56%) were free of AF while median AF burden was 0.7% (IQR: 0.2, 1.6) in patients with an AF burden of more than 0%. A total of 35 patients (54%) were found to have PVR after ablation. Patients with AF recurrence had significantly lower PACS compared to patients with no AF during follow-up (10% ± 6% vs. 14% ± 5%, p = 0.004). No differences in PALS and PCS were observed. Increased PACS remained independently associated with low AF burden following CA after multivariable adjustments for clinical characteristics, comorbidities, and PVR (β=-0.262, p = 0.049) (Figure 1). PALS and PCS did not remain significantly associated with AF burden.

Conclusion

Increased PACS is strongly associated with low AF burden after CA even after adjusting for PVR. This suggests that an analysis of LA function could be useful to stratify patients prior to CA and improve treatment strategies.

Abstract Figure.