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Pradella M, Baraboo JJ, Maroun A, Liu SZ, DiCarlo AL, Chu SH, Hwang JM, Collins MA, Passman R, Heckbert SR, Greenland P, Markl M. Associations between 3D-based Left Atrial Volumetric and Blood Flow Parameters in a Single-Site Cohort of the Multi-Ethnic Study of Atherosclerosis. Radiol Cardiothorac Imaging 2024; 6:e230148. [PMID: 38451190 PMCID: PMC11056754 DOI: 10.1148/ryct.230148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 01/03/2024] [Accepted: 01/18/2024] [Indexed: 03/08/2024]
Abstract
Purpose To investigate associations between left atrial volume (LAV) and function with impaired three-dimensional hemodynamics from four-dimensional flow MRI. Materials and Methods A subcohort of participants from the Multi-Ethnic Study of Atherosclerosis from Northwestern University underwent prospective 1.5-T cardiac MRI including whole-heart four-dimensional flow and short-axis cine imaging between 2019 and 2020. Four-dimensional flow MRI analysis included manual three-dimensional segmentations of the LA and LA appendage (LAA), which were used to quantify LA and LAA peak velocity and blood stasis (% voxels < 0.1 m/sec). Short-axis cine data were used to delineate LA contours on all cardiac time points, and the resulting three-dimensional-based LAVs were extracted for calculation of LA emptying fractions (LAEFtotal, LAEFactive, LAEFpassive). Stepwise multivariable linear models were calculated for each flow parameter (LA stasis, LA peak velocity, LAA stasis, LAA peak velocity) to determine associations with LAV and LAEF. Results This study included 158 participants (mean age, 73 years ± 7 [SD]; 83 [52.5%] female and 75 [47.4%] male participants). In multivariable models, a 1-unit increase of LAEFtotal was associated with decreased LA stasis (β coefficient, -0.47%; P < .001), while increased LAEFactive was associated with increased LA peak velocity (β coefficient, 0.21 cm/sec; P < .001). Furthermore, increased minimum LAV indexed was most associated with impaired LAA flow (higher LAA stasis [β coefficient, 0.65%; P < .001] and lower LAA peak velocity [β coefficient, -0.35 cm/sec; P < .001]). Conclusion Higher minimum LAV and reduced LA function were associated with impaired flow characteristics in the LA and LAA. LAV assessment might therefore be a surrogate measure for LA and LAA flow abnormalities. Keywords: Atherosclerosis, Left Atrial Volume, Left Atrial Blood Flow, 4D Flow MRI Supplemental material is available for this article. © RSNA, 2024.
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Affiliation(s)
- Maurice Pradella
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Justin J. Baraboo
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Anthony Maroun
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Sophia Z. Liu
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Amanda L. DiCarlo
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Stanley H. Chu
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Julia M. Hwang
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Mitchell A. Collins
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Rod Passman
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Susan R. Heckbert
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Philip Greenland
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Michael Markl
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
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Rottmann M, Yoo S, Pfenniger A, Mikhailov A, Benefield B, Johnson DA, Zhang W, Ghosh AK, Kim D, Passman R, Knight BP, Lee DC, Arora R. Use of Atrial Fibrillation Electrograms and T1/T2 Magnetic Resonance Imaging to Define the Progressive Nature of Molecular and Structural Remodeling: A New Paradigm Underlying the Emergence of Persistent Atrial Fibrillation. J Am Heart Assoc 2024; 13:e032514. [PMID: 37930082 PMCID: PMC10944076 DOI: 10.1161/jaha.123.032514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/23/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The temporal progression states of the molecular and structural substrate in atrial fibrillation (AF) are not well understood. We hypothesized that these can be detected by AF electrograms and magnetic resonance imaging parametric mapping. METHODS AND RESULTS AF was induced in 43 dogs (25-35 kg, ≥1 year) by rapid atrial pacing (RAP) (3-33 weeks, 600 beats/min), and 4 controls were used. We performed high-resolution epicardial mapping (UnEmap, 6 atrial regions, both atria, 130 electrodes, distance 2.5 mm) and analyzed electrogram cycle length, dominant frequency, organization index, and peak-to-peak bipolar voltage. Implantable telemetry recordings were used to quantify parasympathetic nerve activity over RAP time. Magnetic resonance imaging native T1, postcontrast T1, T2 mapping, and extracellular volume fraction were assessed (1.5T, Siemens) at baseline and AF. In explanted atrial tissue, DNA oxidative damage (8-hydroxy-2'-deoxyguanosine staining) and percentage of fibrofatty tissue were quantified. Cycle length and organization index decreased (R=0.5, P<0.05; and R=0.5, P<0.05; respectively), and dominant frequency increased (R=0.3, P n.s.) until 80 days of RAP but not thereafter. In contrast, voltage continued to decrease throughout the duration of RAP (R=0.6, P<0.05). Parasympathetic nerve activity increased following RAP and plateaued at 80 days. Magnetic resonance imaging native T1 and T2 times increased with RAP days (R=0.5, P<0.05; R=0.6, P<0.05) in the posterior left atrium throughout RAP. Increased RAP days correlated with increasing 8-hydroxy-2'-deoxyguanosine levels and with fibrosis percentage (R=0.5, P<0.05 for both). CONCLUSIONS A combination of AF electrogram characteristics and T1/T2 magnetic resonance imaging can detect early-stage AF remodeling (autonomic remodeling, oxidative stress) and advanced AF remodeling due to oxidative stress and fibrosis.
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Affiliation(s)
- Markus Rottmann
- Feinberg Cardiovascular and Renal Research InstituteNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Shin Yoo
- Feinberg Cardiovascular and Renal Research InstituteNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Anna Pfenniger
- Feinberg Cardiovascular and Renal Research InstituteNorthwestern University Feinberg School of MedicineChicagoILUSA
- Division of CardiologyNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Aleksei Mikhailov
- Feinberg Cardiovascular and Renal Research InstituteNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Brandon Benefield
- Feinberg Cardiovascular and Renal Research InstituteNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - David A. Johnson
- Feinberg Cardiovascular and Renal Research InstituteNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Wenwei Zhang
- Feinberg Cardiovascular and Renal Research InstituteNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Asish K. Ghosh
- Feinberg Cardiovascular and Renal Research InstituteNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Daniel Kim
- Department of RadiologyNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Rod Passman
- Feinberg Cardiovascular and Renal Research InstituteNorthwestern University Feinberg School of MedicineChicagoILUSA
- Division of CardiologyNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Bradley P. Knight
- Feinberg Cardiovascular and Renal Research InstituteNorthwestern University Feinberg School of MedicineChicagoILUSA
- Division of CardiologyNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Daniel C. Lee
- Feinberg Cardiovascular and Renal Research InstituteNorthwestern University Feinberg School of MedicineChicagoILUSA
- Division of CardiologyNorthwestern University Feinberg School of MedicineChicagoILUSA
- Department of RadiologyNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Rishi Arora
- Feinberg Cardiovascular and Renal Research InstituteNorthwestern University Feinberg School of MedicineChicagoILUSA
- Division of CardiologyNorthwestern University Feinberg School of MedicineChicagoILUSA
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Reynolds MR, Passman R, Swindle J, Mohammadi I, Wright B, Boyle K, Turakhia MP, Mittal S. Comparative effectiveness and healthcare utilization for ambulatory cardiac monitoring strategies in Medicare beneficiaries. Am Heart J 2024; 269:25-34. [PMID: 38072334 DOI: 10.1016/j.ahj.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/19/2023] [Accepted: 12/04/2023] [Indexed: 01/02/2024]
Abstract
BACKGROUND Objective data comparing the diagnostic performance of different ambulatory cardiac monitors (ACMs) are lacking. OBJECTIVES To assess variation in monitoring strategy, clinical outcomes and healthcare utilization in patients undergoing ambulatory monitoring without a pre-existing arrhythmia diagnosis. METHODS Using the full sample (100%) of Medicare claims data, we performed a retrospective cohort study of diagnostic-naïve patients who received first-time ACM in 2017 to 2018 and evaluated arrhythmia encounter diagnosis at 3-months, repeat ACM testing at 6 months, all-cause 90-day emergency department (ED) and inpatient utilization, and cost of different strategies: Holter; long-term continuous monitor (LTCM); non-continuous, event-based external ambulatory event monitor (AEM); and mobile cardiac telemetry (MCT). We secondarily performed a device-specific analysis by manufacturer, identified from unique claim modifier codes. RESULTS ACMs were used in 287,789 patients (AEM = 10.3%; Holter = 53.8%; LTCM = 13.3%; MCT = 22.5%). Device-specific analysis showed that compared to Holter, AEM, MCT, or other LTCM manufacturers, a specific LTCM (ZioⓇ XT 14-day patch, iRhythm Technologies, San Francisco, CA) had the highest adjusted odds of diagnosis and lowest adjusted odds of ACM retesting. Findings were consistent for specific arrhythmia diagnoses of ventricular tachycardia, atrioventricular block, and paroxysmal atrial fibrillation. As a category, LTCM was associated with the lowest 1-year incremental health care expenditures (mean Δ$10,159), followed by Holter ($10,755), AEM ($11,462), and MCT ($12,532). CONCLUSIONS There was large variation in diagnostic monitoring strategy. A specific LTCM was associated with the highest adjusted odds of a new arrhythmia diagnosis and lowest adjusted odds of repeat ACM testing. LTCM as a category had the lowest incremental acute care utilization. Different monitoring strategies may produce different results with respect to diagnosis and care.
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Affiliation(s)
| | - Rod Passman
- Northwestern University School of Medicine, Chicago, IL
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4
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Brienesse S, Passman R, Freedman B. Interruption of oral anticoagulants after atrial fibrillation catheter ablation: the importance of risk stratification. Eur Heart J 2024; 45:535-537. [PMID: 38263516 DOI: 10.1093/eurheartj/ehad874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Affiliation(s)
| | - Rod Passman
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, The University of Sydney, Sydney, NSW 2006, Australia
- Concord Hospital Cardiology and Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia
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5
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Varma N, Han JK, Passman R, Rosman LA, Ghanbari H, Noseworthy P, Avari Silva JN, Deshmukh A, Sanders P, Hindricks G, Lip G, Sridhar AR. Promises and Perils of Consumer Mobile Technologies in Cardiovascular Care: JACC Scientific Statement. J Am Coll Cardiol 2024; 83:611-631. [PMID: 38296406 DOI: 10.1016/j.jacc.2023.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/16/2023] [Indexed: 02/08/2024]
Abstract
Direct-to-consumer (D2C) wearables are becoming increasingly popular in cardiovascular health management because of their affordability and capability to capture diverse health data. Wearables may enable continuous health care provider-patient partnerships and reduce the volume of episodic clinic-based care (thereby reducing health care costs). However, challenges arise from the unregulated use of these devices, including questionable data reliability, potential misinterpretation of information, unintended psychological impacts, and an influx of clinically nonactionable data that may overburden the health care system. Further, these technologies could exacerbate, rather than mitigate, health disparities. Experience with wearables in atrial fibrillation underscores these challenges. The prevalent use of D2C wearables necessitates a collaborative approach among stakeholders to ensure effective integration into cardiovascular care. Wearables are heralding innovative disease screening, diagnosis, and management paradigms, expanding therapeutic avenues, and anchoring personalized medicine.
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Affiliation(s)
- Niraj Varma
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| | - Janet K Han
- Department of Cardiology, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA; Department of Cardiology, David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, California, USA
| | - Rod Passman
- Department of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lindsey Anne Rosman
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Hamid Ghanbari
- Department of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Peter Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Prashanthan Sanders
- Department of Cardiology, University of Adelaide, South Australia, Australia
| | | | - Gregory Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Arun R Sridhar
- Department of Cardiology, Pulse Heart Institute, Seattle, Washington, USA; Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
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Fan L, Hong K, Allen BD, Paul R, Carr JC, Zhang S, Passman R, Robinson JD, Lee DC, Rigsby CK, Kim D. Ultra-rapid, Free-breathing, Real-time Cardiac Cine MRI Using GRASP Amplified with View Sharing and KWIC Filtering. Radiol Cardiothorac Imaging 2024; 6:e230107. [PMID: 38358330 PMCID: PMC10912880 DOI: 10.1148/ryct.230107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 12/06/2023] [Accepted: 01/02/2024] [Indexed: 02/16/2024]
Abstract
Purpose To achieve ultra-high temporal resolution (approximately 20 msec) in free-breathing, real-time cardiac cine MRI using golden-angle radial sparse parallel (GRASP) reconstruction amplified with view sharing (VS) and k-space-weighted image contrast (KWIC) filtering. Materials and Methods Fourteen pediatric patients with congenital heart disease (mean age [SD], 9 years ± 2; 13 male) and 10 adult patients with arrhythmia (mean age, 62 years ± 8; nine male) who underwent both standard breath-hold cine and free-breathing real-time cine using GRASP were retrospectively identified. To achieve high temporal resolution, each time frame was reconstructed using six radial spokes, corresponding to acceleration factors ranging from 24 to 32. To compensate for loss in spatial resolution resulting from over-regularization in GRASP, VS and KWIC filtering were incorporated. The blur metric, visual image quality scores, and biventricular parameters were compared between clinical and real-time cine images. Results In pediatric patients, the incorporation of VS and KWIC into GRASP (ie, GRASP + VS + KWIC) produced significantly (P < .05) sharper x-y-t (blur metric: 0.36 ± 0.03, 0.41 ± 0.03, 0.48 ± 0.03, respectively) and x-y-f (blur metric: 0.28 ± 0.02, 0.31 ± 0.03, 0.37 ± 0.03, respectively) component images compared with GRASP + VS and conventional GRASP. Only the noise score differed significantly between GRASP + VS + KWIC and clinical cine; all visual scores were above the clinically acceptable (3.0) cutoff point. Biventricular volumetric parameters strongly correlated (R2 > 0.85) between clinical and real-time cine images reconstructed with GRASP + VS + KWIC and were in good agreement (relative error < 6% for all parameters). In adult patients, the visual scores of all categories were significantly lower (P < .05) for clinical cine compared with real-time cine with GRASP + VS + KWIC, except for noise (P = .08). Conclusion Incorporating VS and KWIC filtering into GRASP reconstruction enables ultra-high temporal resolution (approximately 20 msec) without significant loss in spatial resolution. Keywords: Cine, View Sharing, k-Space-weighted Image Contrast Filtering, Radial k-Space, Pediatrics, Arrhythmia, GRASP, Compressed Sensing, Real-Time, Free-Breathing Supplemental material is available for this article. © RSNA, 2024.
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Affiliation(s)
- Lexiaozi Fan
- From the Department of Radiology (L.F., K.P.H., B.D.A., R.P., J.C.C.,
S.Z., J.D.R., C.K.R., D.K.), Department of Preventive Medicine, Bluhm
Cardiovascular Institute (R.P.), Department of Pediatrics (J.D.R., C.K.R.), and
Division of Cardiology, Department of Internal Medicine (D.C.L.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Ste 1600, Chicago,
IL 60611; Department of Biomedical Engineering, Northwestern University,
Evanston, Ill (L.F., D.K.); and Division of Cardiology (J.D.R.) and Department
of Medical Imaging (C.K.R.), Ann & Robert H. Lurie Children’s
Hospital of Chicago, Chicago, Ill
| | - KyungPyo Hong
- From the Department of Radiology (L.F., K.P.H., B.D.A., R.P., J.C.C.,
S.Z., J.D.R., C.K.R., D.K.), Department of Preventive Medicine, Bluhm
Cardiovascular Institute (R.P.), Department of Pediatrics (J.D.R., C.K.R.), and
Division of Cardiology, Department of Internal Medicine (D.C.L.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Ste 1600, Chicago,
IL 60611; Department of Biomedical Engineering, Northwestern University,
Evanston, Ill (L.F., D.K.); and Division of Cardiology (J.D.R.) and Department
of Medical Imaging (C.K.R.), Ann & Robert H. Lurie Children’s
Hospital of Chicago, Chicago, Ill
| | - Bradley D. Allen
- From the Department of Radiology (L.F., K.P.H., B.D.A., R.P., J.C.C.,
S.Z., J.D.R., C.K.R., D.K.), Department of Preventive Medicine, Bluhm
Cardiovascular Institute (R.P.), Department of Pediatrics (J.D.R., C.K.R.), and
Division of Cardiology, Department of Internal Medicine (D.C.L.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Ste 1600, Chicago,
IL 60611; Department of Biomedical Engineering, Northwestern University,
Evanston, Ill (L.F., D.K.); and Division of Cardiology (J.D.R.) and Department
of Medical Imaging (C.K.R.), Ann & Robert H. Lurie Children’s
Hospital of Chicago, Chicago, Ill
| | - Rupsa Paul
- From the Department of Radiology (L.F., K.P.H., B.D.A., R.P., J.C.C.,
S.Z., J.D.R., C.K.R., D.K.), Department of Preventive Medicine, Bluhm
Cardiovascular Institute (R.P.), Department of Pediatrics (J.D.R., C.K.R.), and
Division of Cardiology, Department of Internal Medicine (D.C.L.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Ste 1600, Chicago,
IL 60611; Department of Biomedical Engineering, Northwestern University,
Evanston, Ill (L.F., D.K.); and Division of Cardiology (J.D.R.) and Department
of Medical Imaging (C.K.R.), Ann & Robert H. Lurie Children’s
Hospital of Chicago, Chicago, Ill
| | - James C. Carr
- From the Department of Radiology (L.F., K.P.H., B.D.A., R.P., J.C.C.,
S.Z., J.D.R., C.K.R., D.K.), Department of Preventive Medicine, Bluhm
Cardiovascular Institute (R.P.), Department of Pediatrics (J.D.R., C.K.R.), and
Division of Cardiology, Department of Internal Medicine (D.C.L.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Ste 1600, Chicago,
IL 60611; Department of Biomedical Engineering, Northwestern University,
Evanston, Ill (L.F., D.K.); and Division of Cardiology (J.D.R.) and Department
of Medical Imaging (C.K.R.), Ann & Robert H. Lurie Children’s
Hospital of Chicago, Chicago, Ill
| | - Sarah Zhang
- From the Department of Radiology (L.F., K.P.H., B.D.A., R.P., J.C.C.,
S.Z., J.D.R., C.K.R., D.K.), Department of Preventive Medicine, Bluhm
Cardiovascular Institute (R.P.), Department of Pediatrics (J.D.R., C.K.R.), and
Division of Cardiology, Department of Internal Medicine (D.C.L.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Ste 1600, Chicago,
IL 60611; Department of Biomedical Engineering, Northwestern University,
Evanston, Ill (L.F., D.K.); and Division of Cardiology (J.D.R.) and Department
of Medical Imaging (C.K.R.), Ann & Robert H. Lurie Children’s
Hospital of Chicago, Chicago, Ill
| | - Rod Passman
- From the Department of Radiology (L.F., K.P.H., B.D.A., R.P., J.C.C.,
S.Z., J.D.R., C.K.R., D.K.), Department of Preventive Medicine, Bluhm
Cardiovascular Institute (R.P.), Department of Pediatrics (J.D.R., C.K.R.), and
Division of Cardiology, Department of Internal Medicine (D.C.L.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Ste 1600, Chicago,
IL 60611; Department of Biomedical Engineering, Northwestern University,
Evanston, Ill (L.F., D.K.); and Division of Cardiology (J.D.R.) and Department
of Medical Imaging (C.K.R.), Ann & Robert H. Lurie Children’s
Hospital of Chicago, Chicago, Ill
| | - Joshua D. Robinson
- From the Department of Radiology (L.F., K.P.H., B.D.A., R.P., J.C.C.,
S.Z., J.D.R., C.K.R., D.K.), Department of Preventive Medicine, Bluhm
Cardiovascular Institute (R.P.), Department of Pediatrics (J.D.R., C.K.R.), and
Division of Cardiology, Department of Internal Medicine (D.C.L.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Ste 1600, Chicago,
IL 60611; Department of Biomedical Engineering, Northwestern University,
Evanston, Ill (L.F., D.K.); and Division of Cardiology (J.D.R.) and Department
of Medical Imaging (C.K.R.), Ann & Robert H. Lurie Children’s
Hospital of Chicago, Chicago, Ill
| | - Daniel C. Lee
- From the Department of Radiology (L.F., K.P.H., B.D.A., R.P., J.C.C.,
S.Z., J.D.R., C.K.R., D.K.), Department of Preventive Medicine, Bluhm
Cardiovascular Institute (R.P.), Department of Pediatrics (J.D.R., C.K.R.), and
Division of Cardiology, Department of Internal Medicine (D.C.L.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Ste 1600, Chicago,
IL 60611; Department of Biomedical Engineering, Northwestern University,
Evanston, Ill (L.F., D.K.); and Division of Cardiology (J.D.R.) and Department
of Medical Imaging (C.K.R.), Ann & Robert H. Lurie Children’s
Hospital of Chicago, Chicago, Ill
| | - Cynthia K. Rigsby
- From the Department of Radiology (L.F., K.P.H., B.D.A., R.P., J.C.C.,
S.Z., J.D.R., C.K.R., D.K.), Department of Preventive Medicine, Bluhm
Cardiovascular Institute (R.P.), Department of Pediatrics (J.D.R., C.K.R.), and
Division of Cardiology, Department of Internal Medicine (D.C.L.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Ste 1600, Chicago,
IL 60611; Department of Biomedical Engineering, Northwestern University,
Evanston, Ill (L.F., D.K.); and Division of Cardiology (J.D.R.) and Department
of Medical Imaging (C.K.R.), Ann & Robert H. Lurie Children’s
Hospital of Chicago, Chicago, Ill
| | - Daniel Kim
- From the Department of Radiology (L.F., K.P.H., B.D.A., R.P., J.C.C.,
S.Z., J.D.R., C.K.R., D.K.), Department of Preventive Medicine, Bluhm
Cardiovascular Institute (R.P.), Department of Pediatrics (J.D.R., C.K.R.), and
Division of Cardiology, Department of Internal Medicine (D.C.L.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Ste 1600, Chicago,
IL 60611; Department of Biomedical Engineering, Northwestern University,
Evanston, Ill (L.F., D.K.); and Division of Cardiology (J.D.R.) and Department
of Medical Imaging (C.K.R.), Ann & Robert H. Lurie Children’s
Hospital of Chicago, Chicago, Ill
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7
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Nallamothu T, Pradella M, Markl M, Greenland P, Passman R, Elbaz MS. Robust and fast stochastic 4D flow vector-field signature technique for quantifying composite flow dynamics from 4D flow MRI: Application to left atrial flow in atrial fibrillation. Med Image Anal 2024; 92:103065. [PMID: 38113616 DOI: 10.1016/j.media.2023.103065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 11/09/2023] [Accepted: 12/11/2023] [Indexed: 12/21/2023]
Abstract
4D flow MRI is an emerging imaging modality that maps voxel-wise blood flow information as velocity vector fields that is acquired in 7-dimensional image volumes (3 spatial dimensions + 3 velocity directions + time). Blood flow in the cardiovascular system is often complex and composite involving multiple flow dynamics and patterns (e.g., vortex flow, jets, stagnating flow) that occur and interact simultaneously. The spectrum of such complex flow dynamics is embedded in the velocity vector field dynamics derived from 4D Flow MRI. However, current flow metrics cannot fully measure high-dimensional vector-field data and embedded complex composite flow data. Instead, these methods need to break down the vector-field data into secondary scalar fields of individual flow components using fluid dynamics operators. These methods are gradient-based and sensitive to data uncertainties, and only focus on individual flow components of the overall composite flow, therefore potentially underestimating the severity of overall flow changes associated with cardiovascular diseases. To address these limitations, in MICCAI 2021, we introduced a novel comprehensive stochastic 4D Flow vector-field signature technique that works directly on the entire spatiotemporal velocity vector field. This technique uses efficient stochastic gradient-free interrogation of multi-million flow vector-pairs per patient to derive the patient's unique flow profile of the complex composite flow alterations and in real-time processing. The signature technique's probabilistic gradient-free formulation should allow for highly robust quantification despite inherent errors in 4D flow MRI acquisitions. Here, we extend the application of the 4D flow vector-field signature technique to the left atrium to analyze complex composite flow changes in patients with atrial fibrillation. In 128 subjects, we performed extensive sensitivity testing and determined that the vector-field signature technique is highly robust to typical sources of data uncertainties in 4D flow MRI: degradation in spatiotemporal resolution, added Gaussian noise, and segmentation errors. We demonstrate the excellent generalizability of the stochastic convergence from the aorta to the left atrium and between different 4D Flow MRI acquisition protocols. We compare the robustness of our technique to existing advanced flow quantification metrics of kinetic energy, vorticity, and energy loss demonstrating a superior performance of up-to 14-fold. Our results show the potential diagnostic and clinical utility of our signature technique in identifying distinctly altered composite flow signatures in atrial fibrillation patients independent of existing flow metrics.
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Affiliation(s)
- Thara Nallamothu
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States; Biomedical Engineering, Northwestern University, Evanston, IL, United States
| | - Maurice Pradella
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States; Department of Radiology, Clinic of Radiology and Nuclear Medicine, University Hospital of Basel, Basel, Switzerland
| | - Michael Markl
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States; Biomedical Engineering, Northwestern University, Evanston, IL, United States
| | - Philip Greenland
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Rod Passman
- Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Mohammed Sm Elbaz
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.
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8
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DiCarlo AL, Haji-Valizadeh H, Passman R, Greenland P, McCarthy P, Lee DC, Kim D, Markl M. Assessment of Beat-To-Beat Variability in Left Atrial Hemodynamics Using Real Time Phase Contrast MRI in Patients With Atrial Fibrillation. J Magn Reson Imaging 2023; 58:763-771. [PMID: 36468562 PMCID: PMC10239789 DOI: 10.1002/jmri.28550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Hemodynamic assessment of left atrial (LA) flow using phase contrast MRI provides insight into thromboembolic risk in atrial fibrillation (AF). However, conventional flow imaging techniques are averaged over many heartbeats. PURPOSE To evaluate beat-to-beat variability and LA hemodynamics in patients with AF using real time phase contrast (RTPC) MRI. STUDY TYPE Prospective. SUBJECTS Thirty-five patients with history of AF (68 ± 10 years, nine female), 10 healthy controls (57 ± 19 years, four female). FIELD STRENGTH/SEQUENCE 5T, 2D RTPC with through-plane velocity-encoded gradient echo sequence and 4D flow MRI with three-directional velocity-encoded gradient echo sequence. ASSESSMENT RTPC was continuously acquired for a mid-LA slice in all subjects. 4D flow data were interpolated at the RTPC location and normally projected for comparison with RTPC. RR intervals extracted from RTPC were used to calculate heart rate variability (HRV = interquartile range over median × 100%). Patients were classified into low (<9.7%) and high (>9.7%) HRV groups. LA peak/mean velocity and stasis (%velocities < 5.8 cm/sec) were calculated from segmented 2D images. Variability in RTPC flow metrics was quantified by coefficient of variation (CV) over all cycles. STATISTICAL TESTS Pearson's correlation coefficient (r), Bland-Altman analysis, Kruskal-Wallis test. A P value < 0.05 was considered statistically significant. RESULTS RTPC and 4D flow measurements were strongly/significantly correlated for all hemodynamic parameters (R2 = 0.75-0.83) in controls. Twenty-four patients had low HRV (mean = 4 ± 2%) and 11 patients had high HRV (27 ± 9%). In patients, increased HRV was significantly correlated with CV of peak velocity (r = 0.67), mean velocity (r = 0.51), and stasis (r = 0.41). A stepwise decrease in peak/mean velocity and increase in stasis was observed when comparing controls vs. low HRV vs. high HRV groups. Mean velocity and stasis differences were significant for control vs. high HRV groups. CONCLUSIONS RTPC may be suitable for assessing the impact of HRV on hemodynamics and provide insight for AF management in highly arrhythmic patients. EVIDENCE LEVEL 1 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Amanda L DiCarlo
- Department of Radiology, Northwestern University Feinberg School of Medicine
| | - Hassan Haji-Valizadeh
- Department of Radiology, Northwestern University Feinberg School of Medicine
- Department of Biomedical Engineering, Northwestern University McCormick School of Engineering
| | - Rod Passman
- Department of Cardiology, Northwestern University Feinberg School of Medicine
| | - Philip Greenland
- Department of Cardiology, Northwestern University Feinberg School of Medicine
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine
| | - Patrick McCarthy
- Department of Cardiothoracic Surgery, Northwestern University Feinberg School of Medicine
| | - Daniel C Lee
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine
| | - Daniel Kim
- Department of Radiology, Northwestern University Feinberg School of Medicine
- Department of Biomedical Engineering, Northwestern University McCormick School of Engineering
| | - Michael Markl
- Department of Radiology, Northwestern University Feinberg School of Medicine
- Department of Biomedical Engineering, Northwestern University McCormick School of Engineering
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9
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Sayed A, Awad AK, Abdelfattah OM, Elsayed M, Herzallah K, Marine JE, Passman R, Bunch JT. The impact of catheter ablation in patient's heart failure and atrial fibrillation: a meta-analysis of randomized clinical trials. J Interv Card Electrophysiol 2023; 66:1487-1497. [PMID: 36572800 DOI: 10.1007/s10840-022-01451-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/05/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Recent trial data suggest a benefit to catheter ablation (CA) compared to medical therapy for atrial fibrillation (AF) in patients with heart failure (HF). Nevertheless, because of mixed trial evidence, contemporary guidelines give it a class 2 recommendation. Accordingly, we sought to assess the currently available evidence for CA in HF with AF. METHODS Electronic databases were searched to identify randomized clinical trials (RCTs) comparing CA to medical therapy in patients with AF and HF. Study data was pooled using fixed and random effects, and the number needed to treat (NNT) was calculated to gauge absolute risk differences. Heterogeneity was quantified using I2. Our primary outcome was all-cause mortality. RESULTS Nine trials (CA 1075 patients; medical therapy 1083 patients) were included. Ablation reduced the relative risk of all-cause mortality by 31.5% (95% CI 13.7 to 45.6%; NNT = 23), cardiovascular mortality by 39.3% (95% CI 10.9 to 58.7%; NNT = 31), cardiovascular hospitalization by 29.1% (95% CI 9.4 to 44.6%; NNT = 9), and heart failure hospitalization by 28.5% (95% CI 6.5 to 45.4%; NNT = 22). Improvements in quality of life were observed with CA using the Minnesota Living with Heart Failure Questionnaire (mean difference - 5.26; 95% CI - 2.73 to - 7.78) and the Atrial Fibrillation Effect on Quality of Life (mean difference 5.36; 95% CI 2.72 to 8.00). CONCLUSION Compared to medical therapy, CA for AF in patients with HF reduces all-cause mortality, cardiovascular mortality, cardiovascular hospitalizations, and heart failure hospitalizations, and may improve quality of life.
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Affiliation(s)
- Ahmed Sayed
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed K Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Omar M Abdelfattah
- Internal Medicine Department, Morristown Medical Center, Atlantic Health System, Morristown, NJ, USA
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Mahmoud Elsayed
- Section of Cardiac Electrophysiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Joseph E Marine
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rod Passman
- Section of Cardiac Electrophysiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jared T Bunch
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, 30 North 1900 East, Room 4A100, Salt Lake City, UT, 84132, USA.
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10
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Gibson CM, Steinhubl S, Lakkireddy D, Turakhia MP, Passman R, Jones WS, Bunch TJ, Curtis AB, Peterson ED, Ruskin J, Saxon L, Tarino M, Tarakji KG, Marrouche N, Patel M, Harxhi A, Kaul S, Nikolovski J, Juan S, Wildenhaus K, Damaraju CV, Spertus JA. Does early detection of atrial fibrillation reduce the risk of thromboembolic events? Rationale and design of the Heartline study. Am Heart J 2023; 259:30-41. [PMID: 36642226 DOI: 10.1016/j.ahj.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 01/03/2023] [Accepted: 01/07/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND The impact of using direct-to-consumer wearable devices as a means to timely detect atrial fibrillation (AF) and to improve clinical outcomes is unknown. METHODS Heartline is a pragmatic, randomized, and decentralized application-based trial of US participants aged ≥65 years. Two randomized cohorts include adults with possession of an iPhone and without a history of AF and those with a diagnosis of AF taking a direct oral anticoagulant (DOAC) for ≥30 days. Participants within each cohort are randomized (3:1) to either a core digital engagement program (CDEP) via iPhone application (Heartline application) and an Apple Watch (Apple Watch Group) or CDEP alone (iPhone-only Group). The Apple Watch Group has the watch irregular rhythm notification (IRN) feature enabled and access to the ECG application on the Apple Watch. If an IRN notification is issued for suspected AF then the study application instructs participants in the Apple Watch Group to seek medical care. All participants were "watch-naïve" at time of enrollment and have an option to either buy or loan an Apple Watch as part of this study. The primary end point is time from randomization to clinical diagnosis of AF, with confirmation by health care claims. Key secondary endpoint are claims-based incidence of a 6-component composite cardiovascular/systemic embolism/mortality event, DOAC medication use and adherence, costs/health resource utilization, and frequency of hospitalizations for bleeding. All study assessments, including patient-reported outcomes, are conducted through the study application. The target study enrollment is approximately 28,000 participants in total; at time of manuscript submission, a total of 26,485 participants have been enrolled into the study. CONCLUSION The Heartline Study will assess if an Apple Watch with the IRN and ECG application, along with application-facilitated digital health engagement modules, improves time to AF diagnosis and cardiovascular outcomes in a real-world environment. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04276441.
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Affiliation(s)
| | | | | | - Mintu P Turakhia
- Center for Digital Health, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Health Palo Alto Health Care System, Palo Alto, CA
| | - Rod Passman
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - W Schuyler Jones
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - T Jared Bunch
- Cardiovascular Medicine Division, University of Utah School of Medicine, Salt Lake City, UT
| | - Anne B Curtis
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Eric D Peterson
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jeremy Ruskin
- Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - Leslie Saxon
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | | | | | | | - Ante Harxhi
- Janssen Scientific Affairs, LLC, Titusville, NJ
| | | | | | | | | | | | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, MO
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11
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Diener HC, Wachter R, Wong A, Thijs V, Schnabel RB, Ntaios G, Kasner S, Rothwell PM, Passman R, Saver JL, Albers BA, Bernstein RA. Monitoring for atrial fibrillation prior to patent foramen ovale closure after cryptogenic stroke. Int J Stroke 2023; 18:400-407. [PMID: 36050817 PMCID: PMC10037544 DOI: 10.1177/17474930221124412] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients who had a cryptogenic stroke (CS) suspected to be causally related to a patent foramen ovale (PFO) are candidates for percutaneous PFO closure. In such patients, it is important to screen for atrial fibrillation (AF). Limited guidance is available regarding AF monitoring strategies in CS patients with PFO addressing optimal monitoring technology and duration. AIM To provide a narrative review of cardiac rhythm monitoring in CS patients considered for PFO closure, including current practices, stroke recurrences after CS, findings from monitoring studies in CS patients, and predictors for AF detection published in the literature. To propose a personalized strategy for cardiac monitoring in CS patients, accounting for aspects predicting AF detection. SUMMARY OF REVIEW AF detection in CS patients is predicted by age, left atrial enlargement, prolonged PR interval, frequent premature atrial contractions, interatrial conduction block, diabetes, prior brain infarctions, leukoaraiosis, elevated B-type natriuretic peptide (BNP)/N-terminal pro B-type natriuretic peptide (NT-proBNP) levels, and a family history of AF, as well as composed scores (e.g. CHA2DS2-VASc, atrial fibrillation in embolic stroke of undetermined source (AF-ESUS)). The causal role of the PFO may be accounted for by the risk of paradoxical embolism (RoPE) score and/or the PFO-Associated Stroke Causal Likelihood (PASCAL) classification. CONCLUSION A personalized approach to AF detection in CS patients is proposed, accounting for the likelihood of AF detection and aimed at obtaining sufficient confidence regarding the absence of AF in patients considered for PFO closure. In addition, the impact of high-risk PFO features on the monitoring strategy is discussed.
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Affiliation(s)
- Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), Medical Faculty of the University of Duisburg-Essen, Essen, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Andrew Wong
- Neurology Department, Royal Brisbane and Women's Hospital and the University of Queensland, Brisbane, QLD, Australia
| | - Vincent Thijs
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Renate B Schnabel
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Scott Kasner
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Rod Passman
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Bert A Albers
- Albers Clinical Evidence Consultancy, Winterswijk Woold, The Netherlands
| | - Richard A Bernstein
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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12
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Liu AY, Charron J, Fugaro D, Spoolstra S, Kaplan R, Lohrmann G, Gao X, Gay H, Passman R, Kim S, Lin AC, Chicos A, Arora R, Patil K, Pfenniger A, Knight BP, Verma N. Implementation of an intravenous sotalol initiation protocol: Implications for feasibility, safety, and length of stay. J Cardiovasc Electrophysiol 2023; 34:502-506. [PMID: 36640424 PMCID: PMC10699543 DOI: 10.1111/jce.15819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/02/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Oral sotalol initiation requires a multiple-day, inpatient admission to monitor for QT prolongation during loading. A 1-day intravenous (IV) sotalol loading protocol was approved by the United States Food and Drug Administration in March 2020, but limited data on clinical use and administration currently exists. This study describes implementation of an IV sotalol protocol within an integrated health system, provides initial efficacy and safety outcomes, and examines length of stay (LOS) compared with oral sotalol initiation. METHODS IV sotalol was administered according to a prespecified initiation protocol to adult patients with refractory atrial or ventricular arrhythmias. Baseline characteristics, safety and feasibility outcomes, and LOS were compared with patients receiving oral sotalol over a similar time period. RESULTS From January 2021 to June 2022, a total of 29 patients (average age 66.0 ± 8.6 years, 27.6% women) underwent IV sotalol load and 20 patients (average age 60.4 ± 13.9 years, 65.0% women) underwent oral sotalol load. The load was successfully completed in 22/29 (75.9%) patients receiving IV sotalol and 20/20 (100%) of patients receiving oral sotalol, although 7/20 of the oral sotalol patients (35.0%) required dose reduction. Adverse events interrupting IV sotalol infusion included bradycardia (seven patients, 24.1%) and QT prolongation (three patients, 10.3%). No patients receiving IV or oral sotalol developed sustained ventricular arrhythmias before discharge. LOS for patients completing IV load was 2.6 days shorter (mean 1.0 vs. 3.6, p < .001) compared with LOS with oral load. CONCLUSION IV sotalol loading has a safety profile that is similar to oral sotalol. It significantly shortens hospital LOS, potentially leading to large cost savings.
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Affiliation(s)
- Albert Y. Liu
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Jessica Charron
- Division of Cardiology, Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Dana Fugaro
- Division of Cardiology, Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Scott Spoolstra
- Division of Cardiology, Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Rachel Kaplan
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Graham Lohrmann
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Xu Gao
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Hawkins Gay
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Rod Passman
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Susan Kim
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Albert C. Lin
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Alexandru Chicos
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Rishi Arora
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Kaustubha Patil
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Anna Pfenniger
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Bradley P. Knight
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Nishant Verma
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
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13
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Liu SZ, Maroun A, Baraboo JJ, DiCarlo AL, Lee DC, Heckbert SR, Passman R, Markl M, Greenland P, Pradella M. Quantification of left atrial function by the area-length method overestimates left atrial emptying fraction. Eur J Radiol 2023; 160:110705. [PMID: 36701824 PMCID: PMC9946095 DOI: 10.1016/j.ejrad.2023.110705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/21/2022] [Accepted: 01/12/2023] [Indexed: 01/19/2023]
Abstract
PURPOSE The biplane area-length method is commonly used in cardiac magnetic resonance (CMR) to assess left atrial (LA) volume (LAV) and function. Associations between left atrial emptying fraction (LAEF) and clinical outcomes have been reported. However, only limited data are available on the calculation of LAEF using the biplane method compared to 3D assessment. This study aimed to compare volumetric and functional LA parameters obtained from the biplane method with 3D assessment in a large, multiethnic cohort. METHOD 158 participants of MESA (Multi-Ethnic Study of Atherosclerosis) underwent CMR that included standard two- and four-chamber steady-state free precession (SSFP) cine imaging for the biplane method. For 3D-based assessment, short-axis SSFP cine series covering the entire LA were obtained, followed by manual delineation of LA contours to create a time-resolved 3D LAV dataset. Paired t-tests and Bland-Altman plots were used to analyze the data. RESULTS Standard volumetric assessment showed that LAVmin (bias: -8.35 mL, p < 0.001), LAVmax (bias: -9.38 mL, p < 0.001) and LAVpreA (bias: -10.27 mL, p < 0.001) were significantly smaller using the biplane method compared to 3D assessment. Additionally, the biplane method reported significantly higher LAEFtotal (bias: 7.22 %, p < 0.001), LAEFactive (bias: 6.08 %, p < 0.001), and LAEFpassive (bias: 4.51 %, p < 0.001) with wide limits of agreement. CONCLUSIONS LA volumes were underestimated using the biplane method compared to 3D assessment, while LAEF parameters were overestimated. These findings demonstrate a lack of precision using the biplane method for LAEF assessment. Our results support the usage of 3D assessment in specific settings when LA volumetric and functional parameters are in focus.
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Affiliation(s)
- Sophia Z Liu
- Department of Radiology, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
| | - Anthony Maroun
- Department of Radiology, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
| | - Justin J Baraboo
- Department of Radiology, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
| | - Amanda L DiCarlo
- Department of Radiology, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA
| | - Daniel C Lee
- Department of Radiology, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA; Department of Cardiology, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
| | - Susan R Heckbert
- Department of Epidemiology, University of Washington, 3980 15th Ave NE, Seattle, WA 98195, USA.
| | - Rod Passman
- Department of Cardiology, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
| | - Michael Markl
- Department of Radiology, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
| | - Philip Greenland
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
| | - Maurice Pradella
- Department of Radiology, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA; Department of Radiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland.
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14
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Goergen JA, Peigh G, Hsu M, Wilk A, Nayak T, Crosson L, Lenane J, Knight BP, Passman R. Comparison of data quality and monitoring completion rates between clinic and self-applied ECG patches. Heart Rhythm 2023; 20:407-413. [PMID: 36464126 PMCID: PMC9714183 DOI: 10.1016/j.hrthm.2022.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/28/2022] [Accepted: 11/22/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, direct-to-patient, self-applied ECG patch use has substantially increased. There are limited data comparing clinic with self-applied electrocardiogram (ECG) patches. OBJECTIVE The purpose of this study was to compare rates of ECG patch return, percentages of time patches yielded analyzable data (analyzable time), and percentages of prescribed time ECG patches were worn between clinic and self-applied ECG patches before and during COVID-19. METHODS A retrospective analysis of patients prescribed an ECG patch during "pre-COVID" (March 1, 2019, through March 1, 2020) and "COVID" (April 4, 2020, through April 1, 2021) years was performed. ECG patch return rates, mean percentages of analyzable time, and mean percentages of prescribed wear time were compared between clinic and self-applied groups. RESULTS Among the 29,093 ECG patch prescriptions (19% COVID self-applied), the COVID self-applied group had a lower return rate (90.8%) than did both clinic-applied groups (COVID: 97.1%; pre-COVID: 98.1%; P < .001). Among the 28,048 ECG patches (17.5% self-applied) returned for analysis, the COVID self-applied group demonstrated a lower mean percentage of analyzable time (95.9% ± 8.2%) than did both clinic-applied groups (COVID: 96.6% ± 6.6%; pre-COVID 96.6% ± 7.4%; P < .001). There were no differences in the mean percentage of prescribed wear time between groups (pre-COVID clinic-applied: 96.7% ± 34.3%; COVID clinic-applied: 97.4% ± 39.8%; COVID self-applied: 98.1% ± 52.1%; P = .09). CONCLUSION Self-applied ECG patches were returned at a lower rate and had a statistically lower percentage of analyzable time than clinic-applied patches. However, there were no differences between groups in mean percentages of prescribed wear time, and mean percentages of analyzable time were >95% in all groups.
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Affiliation(s)
- Jack A. Goergen
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Graham Peigh
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Mike Hsu
- iRhythm Technologies, San Francisco, California
| | - Alan Wilk
- iRhythm Technologies, San Francisco, California
| | - Tanvi Nayak
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Bradley P. Knight
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Rod Passman
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.
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15
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Goldberger JJ, Green D, Rabbat F, Ringwala S, Andrei AC, Xu Y, Passman R. Effects of catheter ablation of atrial fibrillation on the biomarker profile. Pacing Clin Electrophysiol 2023; 46:132-137. [PMID: 36478408 DOI: 10.1111/pace.14640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 11/03/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Following catheter ablation for atrial fibrillation (AF), there are dynamic changes in the atrial myocardium associated with damage to and necrosis of atrial tissue and other procedure related changes in rhythm and anticoagulation. Early time-dependent changes in biomarkers of necrosis, inflammation, and coagulation have been reported. This study examines mid-term (4-8 weeks post-ablation) changes in biomarkers and explores their ability to predict AF recurrence at one-year. METHODS Twenty-seven patients (mean age 65.4 ± 9.7 years, 30% female) undergoing catheter ablation for AF had peripheral venous blood samples obtained at the time of ablation and 4-8 weeks later. All samples were processed to obtain plasma which was frozen for subsequent analysis. Coagulation studies were performed at the Northwestern Special Hemostasis Laboratory: VWF, ADAMTS13, PAI-1, D-dimer, and TAT complexes. A commercial lab analyzed samples for CRP, cystatin C, fibrinogen, galectin, IL-6, MMP-2, myoglobin, NT-proBNP, PAI-1, TIMP-1, TIMP-2, TPA, and VWF. RESULTS Significant changes were noted with higher levels of ADAMTS13 (p < 0.0001), fibrinogen (p = 0.004), MMP-2 (p = 0.0002), TIMP-2 (p = 0.003), and TPA (p = 0.001) compared to lower levels of TAT (p < 0.0001) and NT-proBNP (p = 0.0001) at follow up post-ablation. One year after ablation, AF had recurred in 11/26 (42%) of patients. None of the biomarker changes predicted the 1-year outcome, and there was no significant association with the use of warfarin versus rivaroxaban. CONCLUSION In patients undergoing catheter ablation for AF, there were significant changes in pre- vs post-ablation levels of multiple biomarkers. However, these changes were not associated with 1-year outcome of AF recurrence.
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Affiliation(s)
- Jeffrey J Goldberger
- Department of Medicine, Cardiovascular Division, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David Green
- Department of Medicine, Northwestern University-Feinberg School of Medicine, Chicago, Illinois, USA
| | - Firas Rabbat
- Department of Medicine, Baptist Hospital, Miami, Florida, USA
| | - Sukit Ringwala
- Bluhm Cardiovascular Institute, Northwestern University-Feinberg School of Medicine, Chicago, Illinois, USA
| | - Adin-Cristian Andrei
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois, USA
| | - Yao Xu
- Bluhm Cardiovascular Institute, Northwestern University-Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rod Passman
- Department of Medicine, Northwestern University-Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Preventive Medicine, Northwestern University, Chicago, Illinois, USA
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16
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Affiliation(s)
- Rod Passman
- Northwestern University Center for Arrhythmia Research and Feinberg School of Medicine, Chicago, Illinois
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17
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Schwamm LH, Kamel H, Granger CB, Piccini JP, Katz JM, Sethi PP, Sidorov EV, Kasner SE, Silverman SB, Merriam TT, Franco N, Ziegler PD, Bernstein RA, Abi-Samra F, Acosta I, Al Balushi A, Al-Awwad A, Alimohammad R, Alkahalifah M, Allred J, Alsorogi M, Arias V, Aroor S, Arora R, Asdaghi N, Asi K, Assar M, Badhwar N, Banchs J, Bansal S, Barrett C, Beaver B, Beldner S, Belt G, Bernabei M, Bernard M, Bhatt N, Black J, Bledsoe D, Bonaguidi H, Bonyak K, Boyd C, Cajavilca C, Caprio F, Carter J, Chancellor B, Chang C, Chaudhary G, Chaudhary S, Cheung P, Ching M, Chinitz L, Chiu D, Chokhawala H, Choudhuri I, Choudry S, Clayton S, Cross J, Cucchiara B, Culpepper A, Daniels J, Dash S, Del Brutto V, Deline C, Delpirou Nouh C, Deo R, Dhamoon M, Dillon G, Donsky A, Doshi A, Downey A, Dukkipati S, Epstein L, Etherton M, Fara M, Fayad PB, Felberg R, Flaster M, Frankel D, Furer S, Gadhia R, Gadient P, Garabelli P, Gibson D, Glotzer T, Goltz D, Gordon D, Graner S, Graybeal D, Grimes MR, Guerrero W, Hanna J, Hao Q, Hasabnis S, Hasan R, Heist EK, Horowitz D, Hourihane JM, Hussein H, Ishida K, Ismail H, Jadonath R, Jamal S, Jamnadas P, Jia J, Johnson M, Jung R, Kalafut M, Kalia J, Kandel A, Kasner S, Katz L, Katz J, Kaur G, Kearney M, Khatib S, Kim S, Kim C, Kipta J, Koch S, Koruth J, Kreger H, Krueger K, Kurian C, LaFranchise E, Lambrakos L, Langan MN, Lee R, Libman R, Lillemoe K, Logan W, Lord A, Lubitz S, Luciano J, Lynch J, Maccaro PC, Magadan A, Magun R, Malik M, Malik A, Manda S, Marulanda-Londono E, Matos Diaz I, Mattera B, McCall-Brown A, Mcclelland N, Meisel K, Memon Z, Mendelson S, Mendoza I, Merriam T, Messe S, Miles WM, Miller M, Mir O, Mitrani R, Morin D, Morris K, Moussavi M, Mowla A, Moye S, Mullen M, Mullins S, Neisen K, Nguyen C, Niazi I, Olson N, Olsovsky G, Ortiz G, Ostrander M, Pakala A, Parker B, Parker M, Passman R, Patel A, Patel A, Pickett RA(D, Polin G, Radoslovich G, Ramano J, Rami T, Ramirez D, Rasmussen J, Ray B, Reddy V, Reddy R, Reeves R, Regenhardt R, Rempe D, Rogers P, Rogers J, Rowe S, Rowley C, Ruff I, Sackett M, Sajjad R, Salem R, Saltzman M, Santangeli P, Saucedo S, Sawyer R, Schaller R, Seeger S, Sethi P, Shang T, Sharma J, Sharma R, Sheinart K, Shukla G, Shultz J, Sidorov E, Silverman S, Simonson J, Singh D, Skalabrin E, Sloane K, Smith M, Smith W, Soik D, Stavrakis S, Stein L, Steinberg JS, Sur N, Switzer D, Talpur N, Tansy A, Tempro K, Thavapalan V, Thomas A, Thomas K, Torres J, Torres L, Tuhrim S, Uddin P, Vidal G, Viswanathan A, Volpi J, Ward K, Weinberger J, Whang W, Wilder M, Willner J, Wright P, Yuan Q, Zhang C, Zhu D, Zide K, Zimmerman J, Zweifler R. Predictors of Atrial Fibrillation in Patients With Stroke Attributed to Large- or Small-Vessel Disease: A Prespecified Secondary Analysis of the STROKE AF Randomized Clinical Trial. JAMA Neurol 2023; 80:99-103. [PMID: 36374508 PMCID: PMC9664367 DOI: 10.1001/jamaneurol.2022.4038] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Importance The Stroke of Known Cause and Underlying Atrial Fibrillation (STROKE AF) trial found that approximately 1 in 8 patients with recent ischemic stroke attributed to large- or small-vessel disease had poststroke atrial fibrillation (AF) detected by an insertable cardiac monitor (ICM) at 12 months. Identifying predictors of AF could be useful when considering an ICM in routine poststroke clinical care. Objective To determine the association between commonly assessed risk factors and poststroke detection of new AF in the STROKE AF cohort monitored by ICM. Design, Setting, and Participants This was a prespecified analysis of a randomized (1:1) clinical trial that enrolled patients between April 1, 2016, and July 12, 2019, with primary follow-up through 2020 and mean (SD) duration of 11.0 (3.0) months. Eligible patients were selected from 33 clinical research sites in the US. Patients had an index stroke attributed to large- or small-vessel disease and were 60 years or older or aged 50 to 59 years with at least 1 additional stroke risk factor. A total of 496 patients were enrolled, and 492 were randomly assigned to study groups (3 did not meet inclusion criteria, and 1 withdrew consent). Patients in the ICM group had the index stroke within 10 days before insertion. Data were analyzed from October 8, 2021, to January 28, 2022. Interventions ICM monitoring vs site-specific usual care (short-duration external cardiac monitoring). Main Outcomes and Measures The ICM device automatically detects AF episodes 2 or more minutes in length; episodes were adjudicated by an expert committee. Cox regression multivariable modeling included all parameters identified in the univariate analysis having P values <.10. AF detection rates were calculated using Kaplan-Meier survival estimates. Results The analysis included the 242 participants randomly assigned to the ICM group in the STROKE AF study. Among 242 patients monitored with ICM, 27 developed AF (mean [SD] age, 66.6 [9.3] years; 144 men [60.0%]; 96 [40.0%] women). Two patients had missing baseline data and exited the study early. Univariate predictors of AF detection included age (per 1-year increments: hazard ratio [HR], 1.05; 95% CI, 1.01-1.09; P = .02), CHA2DS2-VASc score (per point: HR, 1.54; 95% CI, 1.15-2.06; P = .004), chronic obstructive pulmonary disease (HR, 2.49; 95% CI, 0.86-7.20; P = .09), congestive heart failure (CHF; with preserved or reduced ejection fraction: HR, 6.64; 95% CI, 2.29-19.24; P < .001), left atrial enlargement (LAE; HR, 3.63; 95% CI, 1.55-8.47; P = .003), QRS duration (HR, 1.02; 95% CI, 1.00-1.04; P = .04), and kidney dysfunction (HR, 3.58; 95% CI, 1.35-9.46; P = .01). In multivariable modeling (n = 197), only CHF (HR, 5.06; 95% CI, 1.45-17.64; P = .05) and LAE (HR, 3.32; 1.34-8.19; P = .009) remained significant predictors of AF. At 12 months, patients with CHF and/or LAE (40 of 142 patients) had an AF detection rate of 23.4% vs 5.0% for patients with neither (HR, 5.1; 95% CI, 2.0-12.8; P < .001). Conclusions and Relevance Among patients with ischemic stroke attributed to large- or small-vessel disease, CHF and LAE were associated with a significantly increased risk of poststroke AF detection. These patients may benefit most from the use of ICMs as part of a secondary stroke prevention strategy. However, the study was not powered for clinical predictors of AF, and therefore, other clinical characteristics may not have reached statistical significance. Trial Registration ClinicalTrials.gov Identifier: NCT02700945.
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Affiliation(s)
- Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, New York,Deputy Editor, JAMA Neurology
| | - Christopher B. Granger
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jonathan P. Piccini
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey M. Katz
- Department of Neurology and Radiology, North Shore University Hospital, Manhasset, New York
| | - Pramod P. Sethi
- Guilford Neurology Associates, Moses H. Cone Hospital, Greensboro, North Carolina
| | - Evgeny V. Sidorov
- Department of Neurology, The University of Oklahoma Health Sciences Center, Oklahoma City
| | - Scott E. Kasner
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | - Noreli Franco
- Clinical Department, Medtronic, Minneapolis, Minnesota
| | | | - Richard A. Bernstein
- Davee Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, Illinois
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18
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Jones AE, McCarty MM, Cameron KA, Cavanaugh KL, Steinberg BA, Passman R, Kansal P, Guzman A, Chen E, Zhong L, Fagerlin A, Hargraves I, Montori VM, Brito JP, Noseworthy PA, Ozanne EM. Development of Complementary Encounter and Patient Decision Aids for Shared Decision Making about Stroke Prevention in Atrial Fibrillation. MDM Policy Pract 2023; 8:23814683231178033. [PMID: 38178866 PMCID: PMC10765759 DOI: 10.1177/23814683231178033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/06/2023] [Indexed: 01/06/2024] Open
Abstract
Introduction Decision aids (DAs) are helpful instruments used to support shared decision making (SDM). Patients with atrial fibrillation (AF) face complex decisions regarding stroke prevention strategies. While a few DAs have been made for AF stroke prevention, an encounter DA (EDA) and patient DA (PDA) have not been created to be used in conjunction with each other before. Design Using iterative user-centered design, we developed 2 DAs for anticoagulation choice and stroke prevention in AF. Prototypes were created, and we elicited feedback from patients and experts via observations of encounters, usability testing, and semistructured interviews. Results User testing was done with 33 experts (in AF and SDM) and 51 patients from 6 institutions. The EDA and PDA underwent 1 and 4 major iterations, respectively. Major differences between the DAs included AF pathophysiology and a preparation to meet with the clinician in the PDA as well as different language throughout. Content areas included personalized stroke risk, differences between anticoagulants, and risks of bleeding. Based on user feedback, developers 1) addressed feelings of isolation with AF, 2) improved navigation options, 3) modified content and flow for users new to AF and those experienced with AF, 4) updated stroke risk pictographs, and 5) added structure to the preparation for decision making in the PDA. Limitations These DAs focus only on anticoagulation for stroke prevention and are online, which may limit participation for those less comfortable with technology. Conclusions Designing complementary DAs for use in tandem or separately is a new method to support SDM between patients and clinicians. Extensive user testing is essential to creating high-quality tools that best meet the needs of those using them. Highlights First-time complementary encounter and patient decision aids have been designed to work together or separately.User feedback led to greater structure and different experiences for patients naïve or experienced with anticoagulants in patient decision aids.Online tools allow for easier dissemination, use in telehealth visits, and updating as new evidence comes out.
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Affiliation(s)
- Aubrey E. Jones
- College of Pharmacy, Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
| | - Madeleine M. McCarty
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Kenzie A. Cameron
- Feinberg School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, IL, USA
| | - Kerri L. Cavanaugh
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benjamin A. Steinberg
- School of Medicine, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, USA
| | - Rod Passman
- Feinberg School of Medicine, Department of Medicine, Division of Cardiology, Northwestern University, Chicago, IL, USA
| | - Preeti Kansal
- Feinberg School of Medicine, Department of Medicine, Division of Cardiology, Northwestern University, Chicago, IL, USA
| | - Adriana Guzman
- Feinberg School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, IL, USA
| | - Emily Chen
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lingzi Zhong
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Angela Fagerlin
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, USA
| | - Ian Hargraves
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Victor M. Montori
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Juan P. Brito
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | - Elissa M. Ozanne
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
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19
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Abstract
PURPOSE OF REVIEW Atrial fibrillation is associated with a significant increase in stroke and systemic embolism. This review explores the areas of stroke prevention. RECENT FINDINGS In the last decade, NOAC has overtaken warfarin as the anticoagulant of choice for stroke prevention in AF. For patients unable to take anticoagulation, LAA closure has proven to be a valid option. The use of digital devices has led to widespread consumer-directed AF screening. It remains to be determined if all device detect AF pose the same amount of risk as recent studies have shown that short and infrequent episodes of AF may not benefit from anticoagulation. Stroke prevention is paramount in the management of AF. In this review we describe the risk factors contributing to stroke, recent advances in antithrombotic therapies, and the increasing role of digital health in guiding AF detection and stroke prevention.
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Affiliation(s)
- Xu Gao
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rod Passman
- Northwestern Center for Arrhythmia Research, Northwestern University Feinberg School of Medicine, 676 North St. Claire, Suite 600, Chicago, IL, 60657, USA.
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20
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Kawamura I, Kuno T, Sahashi Y, Tanaka Y, Passman R, Briasoulis A, Malik AH. Thirty-day readmission rate of same-day discharge protocol after left atrial appendage occlusion: A propensity score-matched analysis from the National Readmission Database. Heart Rhythm 2022; 19:1819-1825. [PMID: 35835364 DOI: 10.1016/j.hrthm.2022.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/27/2022] [Accepted: 07/02/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Given the reduction in periprocedural complication rates, same-day discharge (SDD) after percutaneous left atrial appendage closure (LAAC) could be beneficial. To date, little data exist comparing the standard overnight stay (ONS) vs SDD after LAAC. OBJECTIVE The purpose of this study was to investigate the safety and efficacy of SDD compared with ONS. METHODS A retrospective cohort study of LAAC procedures performed in the United States from 2015 to 2019 was conducted using the US Nationwide Readmission Database. The primary outcome was all-cause 30-day readmission after discharge in patients who underwent LAAC, and a secondary outcome was requiring total health care cost. A 1:1 propensity score matching was conducted for adjustment. Multivariate Cox proportional hazards regression was also performed to estimate the hazard ratio for all-cause readmission within 30 days of LAAC. RESULTS Of 48,953 patients (mean age 76.0 ± 7.9 years), 972 patients (1.99%) were discharged on the same day after LAAC (SDD group) and the remaining 47,981 patients stayed at least 1 night (ONS group). A propensity score-matched analysis generated 961 matched pairs in each group. The 30-day readmission rate after discharge was similar between the groups (SDD vs ONS: 8.5% vs 9.8%; P = .31; hazard ratio 1.13; 95% confidence interval 0.78-1.63; P = .53). The total required health care cost was significantly lower in the SDD group ($23,720 [$18,075-$29,416] vs $25,877 [$19,906-$32,748]; P < .01). Gastrointestinal bleeding was the major cause for readmission (SDD vs ONS: 14.7% vs 15.1%; P = .95), but stroke and pericardial effusion were rare. CONCLUSION In patients without procedure-related complications, SDD is a safe and cost-effective protocol.
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Affiliation(s)
- Iwanari Kawamura
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Yuki Sahashi
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan; Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan; Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Japan
| | - Yoshihiro Tanaka
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Center for Arrhythmia Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rod Passman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Center for Arrhythmia Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Aaqib H Malik
- Department of Cardiology, Westchester Medical Center, Valhalla, New York
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21
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Churyla A, Passman R, McCarthy PM, Kislitsina ON, Kruse J, Cox JL. Staged hybrid totally thoracoscopic maze and catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol 2022; 33:1961-1965. [PMID: 35695792 PMCID: PMC9544946 DOI: 10.1111/jce.15594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/31/2022] [Accepted: 06/01/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) is a growing health problem and is associated with increased risk of stroke. The Cox-Maze surgical procedure has offered the highest success rate, but utilization of this technique is low due to procedure invasiveness and complexity. Advances in catheter ablation and minimally invasive surgical techniques offer new options for AF treatment. METHODS In this review, we describe current trends and outcomes of minimally invasive treatment of persistent and long-standing persistent AF. RESULTS Treatment of persistent and long-standing persistent AF can be successfully treated using a team approach combining cardiac surgery and electrophysiology procedures. With this approach, the 1-year freedom from AF off antiarrhythmic drugs was 85%. DISCUSSION There are a variety of techniques and approaches used around the world as technology evolves to help develop new treatment strategies for AF. Our report will focus on a hybrid treatment approach using surgical and electrophysiology approaches providing enhanced treatment options by replicating Cox-Maze IV lesions using skills from each specialty. Closure of the left atrial appendage as part of these procedures enhances protection from late stroke. A team approach provides a cohesive evaluation, treatment, and monitoring plan for patients. Development of successful, less invasive treatment options will help address the growing population of patients with AF.
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Affiliation(s)
- Andrei Churyla
- Department of Surgery, Division of Cardiac Surgery, Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - Rod Passman
- Department of Medicine, Division of Cardiology, Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - Patrick M McCarthy
- Department of Surgery, Division of Cardiac Surgery, Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - Olga N Kislitsina
- Department of Medicine, Division of Cardiology, Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jane Kruse
- Department of Surgery, Division of Cardiac Surgery, Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - James L Cox
- Department of Surgery, Division of Cardiac Surgery, Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
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22
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Hughes ZH, Shah NS, Tanaka Y, Hammond MM, Passman R, Khan SS. Rural-Urban Temporal Trends for Sudden Cardiac Death in the United States, 1999-2019. JACC Clin Electrophysiol 2022; 8:382-384. [PMID: 35331435 DOI: 10.1016/j.jacep.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/01/2021] [Accepted: 12/11/2021] [Indexed: 11/26/2022]
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23
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Passman R, Freedman B. Updated USPSTF Guidelines for Screening for Atrial Fibrillation. JAMA Cardiol 2022; 7:247-249. [DOI: 10.1001/jamacardio.2021.5873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Rod Passman
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Northwestern University Center for Arrhythmia Research, Chicago, Illinois
| | - Ben Freedman
- The Heart Research Institute, Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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24
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Nguyen BT, Bhusal B, Rahsepar AA, Fawcett K, Lin S, Marks DS, Passman R, Nieto D, Niemzcura R, Golestanirad L. Safety of MRI in patients with retained cardiac leads. Magn Reson Med 2021; 87:2464-2480. [PMID: 34958685 PMCID: PMC8919805 DOI: 10.1002/mrm.29116] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 11/18/2021] [Accepted: 11/20/2021] [Indexed: 11/17/2022]
Abstract
Purpose To evaluate the safety of MRI in patients with fragmented retained leads (FRLs) through numerical simulation and phantom experiments. Methods Electromagnetic and thermal simulations were performed to determine the worst‐case RF heating of 10 patient‐derived FRL models during MRI at 1.5 T and 3 T and at imaging landmarks corresponding to head, chest, and abdomen. RF heating measurements were performed in phantoms implanted with reconstructed FRL models that produced highest heating in numerical simulations. The potential for unintended tissue stimulation was assessed through a conservative estimation of the electric field induced in the tissue due to gradient‐induced voltages developed along the length of FRLs. Results In simulations under conservative approach, RF exposure at B1+ ≤ 2 µT generated cumulative equivalent minutes (CEM)43 < 40 at all imaging landmarks at both 1.5 T and 3 T, indicating no thermal damage for acquisition times (TAs) < 10 min. In experiments, the maximum temperature rise when FRLs were positioned at the location of maximum electric field exposure was measured to be 2.4°C at 3 T and 2.1°C at 1.5 T. Electric fields induced in the tissue due to gradient‐induced voltages remained below the threshold for cardiac tissue stimulation in all cases. Conclusions Simulation and experimental results indicate that patients with FRLs can be scanned safely at both 1.5 T and 3 T with most clinical pulse sequences.
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Affiliation(s)
- Bach T Nguyen
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Bhumi Bhusal
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Amir Ali Rahsepar
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kate Fawcett
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Stella Lin
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Daniel S Marks
- Department of Electrophysiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Rod Passman
- Department of Electrophysiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Donny Nieto
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Richard Niemzcura
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Laleh Golestanirad
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, Illinois, USA
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25
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Sahashi Y, Kuno T, Tanaka Y, Passman R, Briasoulis A, Malik AH. The 30-day readmission rate of same-day discharge protocol following catheter ablation for atrial fibrillation: a propensity score-matched analysis from National Readmission Database. Europace 2021; 24:755-761. [PMID: 34904164 DOI: 10.1093/europace/euab296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 11/10/2021] [Indexed: 01/17/2023] Open
Abstract
AIMS The effectiveness and safety of same-day discharge (SDD) for catheter ablation (CA) for atrial fibrillation (AF) has not been fully elucidated using a large nationwide database. This study aimed to evaluate the all-cause readmission rates within 30-days among patients receiving CA for AF with an SDD protocol compared with a conventional overnight stay (ONS). METHODS AND RESULTS We performed a retrospective cohort study using the US Nationwide Readmission Database. The primary outcome was all-cause 30-day readmission following discharge in patients receiving CA and a secondary outcome was requiring total healthcare cost. A 1 : 3 propensity score matching was conducted to compare the safety and efficacy within both SDD and ONS group. Among 30 776 patients [mean 67.2 ± 11.4 years, 12 590 female (41.5%)] who received CA from 2016 through 2018, 440 (1.42%) patients were discharged on the same-day following CA (SDD group), and the remaining 30 336 patients stayed at least one night in the hospital (ONS group). A propensity score analysis generated 1751 matched pairs (440 in the SDD group; 1311 in the ONS group). The 30-day readmission following discharge was not significantly higher in the SDD group than the ONS group (SDD vs. ONS: 12.7% vs. 9.7%; hazard ratio: 1.17, 95% confidence interval: 0.76-1.81, P = 0.47). Healthcare cost was significantly higher in the ONS group ($25 237 ± 14 036 vs. $30 749 ± 16 383; P < 0.01). CONCLUSION In this nationwide database study, there was no significant difference in the all-cause 30-day readmission following SDD for CA compared with ONS.
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Affiliation(s)
- Yuki Sahashi
- Department of Cardiovascular Medicine, Gifu Heart Center, 4-14-4, Yabutaminami, Gifu 500-8384, Japan.,Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan.,Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Japan
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA.,Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Yoshihiro Tanaka
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Center for Arrhythmia Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rod Passman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Center for Arrhythmia Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Aaqib H Malik
- Division of Cardiology, Westchester Medical Center, Valhalla, NY, USA
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26
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Chung MK, Fagerlin A, Wang PJ, Ajayi TB, Allen LA, Baykaner T, Benjamin EJ, Branda M, Cavanaugh KL, Chen LY, Crossley GH, Delaney RK, Eckhardt LL, Grady KL, Hargraves IG, Hills MT, Kalscheur MM, Kramer DB, Kunneman M, Lampert R, Langford AT, Lewis KB, Lu Y, Mandrola JM, Martinez K, Matlock DD, McCarthy SR, Montori VM, Noseworthy PA, Orland KM, Ozanne E, Passman R, Pundi K, Roden DM, Saarel EV, Schmidt MM, Sears SF, Stacey D, Stafford RS, Steinberg BA, Wass SY, Wright JM. Shared Decision Making in Cardiac Electrophysiology Procedures and Arrhythmia Management. Circ Arrhythm Electrophysiol 2021; 14:e007958. [PMID: 34865518 PMCID: PMC8692382 DOI: 10.1161/circep.121.007958] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Shared decision making (SDM) has been advocated to improve patient care, patient decision acceptance, patient-provider communication, patient motivation, adherence, and patient reported outcomes. Documentation of SDM is endorsed in several society guidelines and is a condition of reimbursement for selected cardiovascular and cardiac arrhythmia procedures. However, many clinicians argue that SDM already occurs with clinical encounter discussions or the process of obtaining informed consent and note the additional imposed workload of using and documenting decision aids without validated tools or evidence that they improve clinical outcomes. In reality, SDM is a process and can be done without decision tools, although the process may be variable. Also, SDM advocates counter that the low-risk process of SDM need not be held to the high bar of demonstrating clinical benefit and that increasing the quality of decision making should be sufficient. Our review leverages a multidisciplinary group of experts in cardiology, cardiac electrophysiology, epidemiology, and SDM, as well as a patient advocate. Our goal is to examine and assess SDM methodology, tools, and available evidence on outcomes in patients with heart rhythm disorders to help determine the value of SDM, assess its possible impact on electrophysiological procedures and cardiac arrhythmia management, better inform regulatory requirements, and identify gaps in knowledge and future needs.
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Affiliation(s)
| | - Angela Fagerlin
- University of Utah, Salt Lake City, UT
- Salt Lake City Veterans Affairs Informatics Decision-Enhancement and Analytic Sciences Center for Innovation, Salt Lake City, UT
| | | | | | | | | | | | - Megan Branda
- University of Colorado, Aurora, CO
- Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | | | | | | | | | - Marleen Kunneman
- Mayo Clinic, Rochester, MN
- Leiden University Medical Center, Leiden, the Netherlands
| | | | | | | | - Ying Lu
- Stanford University, Stanford, CA
| | | | | | | | | | | | | | | | | | | | | | - Dan M. Roden
- Vanderbilt University Medical Center, Nashville, TN
| | | | | | | | | | | | | | - Sojin Youn Wass
- Cleveland Clinic, Cleveland, OH
- University Hospitals Cleveland Medical Center, Cleveland, OH
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27
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Varma N, Cygankiewicz I, Turakhia M, Heidbuchel H, Hu Y, Chen LY, Couderc JP, Cronin EM, Estep JD, Grieten L, Lane DA, Mehra R, Page A, Passman R, Piccini J, Piotrowicz E, Piotrowicz R, Platonov PG, Ribeiro AL, Rich RE, Russo AM, Slotwiner D, Steinberg JS, Svennberg E. Erratum: Erratum to: 2021 ISHNE / HRS / EHRA / APHRS Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology / Heart Rhythm Society / European Heart Rhythm Association / Asia Pacific Heart Rhythm Society. Eur Heart J Digit Health 2021; 2:727. [PMID: 36716110 PMCID: PMC9707943 DOI: 10.1093/ehjdh/ztab086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
[This corrects the article DOI: 10.1093/ehjdh/ztab001.].
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28
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Kaplan RM, Narang A, Gay H, Gao X, Gibreal M, Arora R, Chicos A, Kim S, Passman R, Patil K, Pfenniger A, Verma N, Lin A, Knight BP. Use of a novel 4D intracardiac echocardiography catheter to guide interventional electrophysiology procedures. J Cardiovasc Electrophysiol 2021; 32:3117-3124. [PMID: 34554627 DOI: 10.1111/jce.15251] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/05/2021] [Accepted: 09/15/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Standard two-dimensional (2D), phased-array intracardiac echocardiography (ICE) is routinely used to guide interventional electrophysiology (EP) procedures. A novel four-dimensional (4D) ICE catheter (VeriSight Pro, Philips) can obtain 2D and three-dimensional (3D) volumetric images and cine-videos in real-time (4D). The purpose of this study was to determine the early feasibility and safety of this 4D ICE catheter during EP procedures. METHODS The 4D ICE catheter was placed from the femoral vein in ten patients into various cardiac chambers to guide EP procedures requiring transseptal catheterization, including ablation for atrial fibrillation and left atrial appendage closure. 2D- and 3D-ICE images were acquired in real-time by the electrophysiologist. A dedicated imaging expert performed digital steering to optimize and postprocess 4D images. RESULTS Eight patients underwent pulmonary vein isolation (cryoballoon in seven patients, pulsed field ablation in one, additional radiofrequency left atrial ablation in one). Two patients underwent left atrial appendage closure. High quality images of cardiac structures, transseptal catheterization equipment, guide sheaths, ablation tools, and closure devices were acquired with the ICE catheter tip positioned in the right atrium, left atrium, pulmonary vein, coronary sinus, right ventricle, and pulmonary artery. There were no complications. CONCLUSION This is the first experience of a novel deflectable 4D ICE catheter used to guide EP procedures. 4D ICE imaging is safe and allows for acquisition of high-quality 2D and 3D images in real-time. Further use of 4D ICE will be needed to determine its added value for each EP procedure type.
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Affiliation(s)
- Rachel M Kaplan
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Akhil Narang
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Hawkins Gay
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Xu Gao
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Mohammed Gibreal
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Rishi Arora
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Alexandru Chicos
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Susan Kim
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Rod Passman
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Kaustubha Patil
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Anna Pfenniger
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Nishant Verma
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Albert Lin
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Bradley P Knight
- Division of Cardiology, Center for Heart Rhythm Disorders, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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29
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Marot JE, Tanaka Y, Witting C, Khan SS, Passman R. B-PO02-120 RACIAL DIFFERENCES IN PROPORTION OF ATRIAL FIBRILLATION PATIENTS WHO VISIT ELECTROPHYSIOLOGY AND UNDERGO CATHETER ABLATION. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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30
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Abstract
Background Prevalence of atrial fibrillation (AF) continues to increase and is associated with significant cardiovascular morbidity and mortality. To inform prevention strategies aimed at reducing the burden of AF, we sought to quantify trends in cardiovascular mortality related to AF in the United States. Methods and Results We performed serial cross‐sectional analyses of national death certificate data for cardiovascular mortality related to AF, whereby cardiovascular disease was listed as underlying cause of death and AF as multiple cause of death among adults aged 35 to 84 years using the Centers for Disease Control and Prevention's Wide‐Ranging Online Data for Epidemiologic Research. We calculated age‐adjusted mortality rates per 100 000 population and examined trends over time, estimating average annual percentage change using the Joinpoint Regression Program. Subgroup analyses were performed by race‐sex and across 2 age groups (younger: 35–64 years; older: 65–84 years). A total of 276 373 cardiovascular deaths related to AF were identified in the United States between 2011 and 2018 in decedents aged 35 to 84 years. Age‐adjusted mortality rate increased from 18.0 (95% CI, 17.8–18.2) to 22.3 (95% CI, 22.0–22.4) per 100 000 population between 2011 and 2018. The increase in age‐adjusted mortality rate (average annual percentage change) between 2011 and 2018 was greater among younger decedents (7.4% per year [95% CI, 6.8%–8.0%]) compared with older decedents (3.0% per year [95% CI, 2.6%–3.4%]). Conclusions Cardiovascular deaths related to AF are increasing, especially among younger adults, and warrant greater attention to prevention earlier in the life course.
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Affiliation(s)
- Yoshihiro Tanaka
- Department of Preventive Medicine Northwestern University, Feinberg School of Medicine Chicago IL.,Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Nilay S Shah
- Department of Preventive Medicine Northwestern University, Feinberg School of Medicine Chicago IL.,Division of Cardiology Northwestern University, Feinberg School of Medicine Chicago IL
| | - Rod Passman
- Department of Preventive Medicine Northwestern University, Feinberg School of Medicine Chicago IL.,Division of Cardiology Northwestern University, Feinberg School of Medicine Chicago IL
| | - Philip Greenland
- Department of Preventive Medicine Northwestern University, Feinberg School of Medicine Chicago IL.,Division of Cardiology Northwestern University, Feinberg School of Medicine Chicago IL
| | - Donald M Lloyd-Jones
- Department of Preventive Medicine Northwestern University, Feinberg School of Medicine Chicago IL.,Division of Cardiology Northwestern University, Feinberg School of Medicine Chicago IL
| | - Sadiya S Khan
- Department of Preventive Medicine Northwestern University, Feinberg School of Medicine Chicago IL.,Division of Cardiology Northwestern University, Feinberg School of Medicine Chicago IL
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31
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Tanaka Y, Matsuyama S, Tada H, Hayashi K, Takamura M, Kawashiri MA, Passman R, Greenland P. Association of Lower Urinary Tract Symptoms Based on the International Prostate Symptom Score and Cardiovascular Disease. Circ J 2021; 85:2092-2099. [PMID: 34219077 DOI: 10.1253/circj.cj-21-0278] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Because it is unclear whether lower urinary tract symptoms (LUTS) are associated with cardiovascular disease (CVD) in the Japanese population, we explored the association in general Japanese men aged 55-75 years.Methods and Results:The cross-sectional study included male participants who had both national health checkup data and the International Prostate Symptom Score (IPSS) in the same calendar year between 2009 and 2017. LUTS severity was evaluated by IPSS. A robust Poisson regression model was used to assess the association between LUTS severity and the composite CVD outcome [coronary artery disease (CAD), stroke, or atrial fibrillation (AF)] and each component of the composite outcome. Prevalence ratio (PR) was adjusted for conventional cardiovascular risk factors. Of 16,781 male participants (mean age, 67±5 years), mild LUTS were observed in 9,243 (55.1%); moderate, 6,445 (38.4%); and severe, 1,093 (6.5%). Compared with the mild LUTS group, moderate LUTS [PR 1.18, 95% confidence interval (CI) 1.10-1.25, P<0.001] and severe LUTS (PR 1.38, 95% CI 1.24-1.53, P<0.001) were significantly associated with a higher prevalence of CVD. LUTS severity was associated with higher prevalence of CAD and stroke, but not AF. CONCLUSIONS The severity of LUTS was associated with a higher prevalence of CVD, especially CAD and stroke, independent of conventional CVD risk factors.
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Affiliation(s)
- Yoshihiro Tanaka
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine.,Center for Arrhythmia Research, Northwestern University Feinberg School of Medicine.,Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | | | - Hayato Tada
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Masayuki Takamura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Masa-Aki Kawashiri
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Rod Passman
- Center for Arrhythmia Research, Northwestern University Feinberg School of Medicine.,Division of Cardiology, Northwestern University Feinberg School of Medicine
| | - Philip Greenland
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine
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32
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Albers GW, Bernstein R, Brachmann J, Camm AJ, Fromm P, Goto S, Granger CB, Hohnloser SH, Hylek E, Krieger D, Passman R, Pines JM, Kowey P. Reexamination of the Embolic Stroke of Undetermined Source Concept. Stroke 2021; 52:2715-2722. [PMID: 34192898 DOI: 10.1161/strokeaha.121.035208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Occult atrial fibrillation (AF) is a leading cause of stroke of unclear cause. The optimal approach to secondary stroke prevention for these patients remains elusive. The term embolic stroke of undetermined source (ESUS) was coined to describe ischemic strokes in which the radiographic features demonstrate territorial infarcts resembling those seen in patients with confirmed sources of embolism but without a clear source of embolism detected. It was assumed that patients with ESUS had a high rate of occult AF and would benefit from treatment with direct oral anticoagulants, which are at least as effective as vitamin K antagonists for secondary stroke prevention in patients with AF, but with a much lower risk of intracerebral hemorrhage. Two recent large randomized trials failed to show superiority of direct oral anticoagulants over aspirin in ESUS patients. These findings prompt a reexamination of the ESUS concept, with the goal of improving specificity for detecting patients with a cardioembolic cause. Based on the negative trial results, there is renewed interest in the role of long-term cardiac monitoring for AF in patients who fit the current ESUS definition, as well as the clinical implication of detecting AF. Ongoing trials are exploring these questions. Current ESUS definitions do not accurately detect the patients who should be prescribed direct oral anticoagulants, potentially because occult AF is less common than expected in these patients and/or anticoagulants may be less beneficial in patients with ESUS but no AF than they are for patients with stroke with established AF. More specific criteria to identify patients who may be at higher risk for occult AF and reduce their risk of subsequent stroke have been developed and are being tested in ongoing clinical trials.
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Affiliation(s)
- Gregory W Albers
- Department of Neurology and the Stanford Stroke Center, Stanford Medical Center, CA (G.W.A.)
| | | | - Johannes Brachmann
- REGIOMED Centrum for Cardiology and Angiology, Kliniken Coburg, II Med Klinik, Germany (J.B.)
| | - A John Camm
- St. George's University of London, United Kingdom (A.J.C.)
| | - Peter Fromm
- Mount Sinai South Nassau, Oceanside, NY (P.F.)
| | - Shinya Goto
- Tokai University School of Medicine, Tokyo, Japan (S.G.)
| | | | | | | | - Derk Krieger
- Mediclinic City Hospital, Mohamed Bin Rashid University, Dubai Health Care City, Dubai, United Arab Emirates (D.K.)
| | - Rod Passman
- Northwestern Memorial Hospital, Chicago, IL (R.P.)
| | | | - Peter Kowey
- Lankenau Hospital and Medical Research Center, Wynnewood, PA (P.K.)
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33
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Besler E, Mathur P, Gay H, Passman R, Sahakian A. Inter-Patient Atrial Flutter Classification Using FFT-Based Features and a Low-Variance Stacking Classifier. IEEE Trans Biomed Eng 2021; 69:156-164. [PMID: 34161233 DOI: 10.1109/tbme.2021.3090051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Atrial Flutter (AFL) is a supraventricular tachyarrhythmia typically arising from a macroreentry circuit that can have variable atrial anatomy. It is often treated by catheter ablation, the success of which depends upon the correct determination of the electroanatomic circuit, generally through invasive electrophysiological (EP) study. We hypothesized that machine learning (ML) methods applied to the diagnostic 12-lead surface electrocardiogram (ECG) could determine the specific circuit prior to any invasive EP study. METHODS The 12-lead ECGs were reduced to eight independent leads: I, II, V1 V6. Through an algorithm using ventricular complex cancellation methods, windows of atrial activity in the ECG were uncovered and spectra were generated. Three ML classifier approaches were applied: Support Vector Machine (SVM), Random Forest (RF) and k-Nearest Neighbors (KNN), and their outputs combined using soft voting. RESULTS Ten-second surface ECGs taken from 419 AFL patients prior to invasive EP study and ablation were analyzed retrospectively. Of the 419 patients, 285 had typical cavotricuspid isthmus (CTI)-dependent AFL, 41 had atypical right-atrial AFL and 93 had left-atrial AFL, as determined during the subsequent EP study. Lead V5 was found to be most useful giving a test accuracy of 98\% and f1 score of 0.97. CONCLUSION We conclude that ML methods have the potential to automatically determine the AFL macroreentry circuit from the surface ECG. SIGNIFICANCE The AFL classification method presented in this investigation achieves 95+\% accuracy on an unbalanced inter-patient dataset which has important clinical applications.
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34
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Smith H, Li H, Brandts-Longtin O, Yeung C, Maziak D, Gilbert S, Villeneuve PJ, Sundaresan S, Passman R, Shamji F, Seely AJE. External validity of a model to predict postoperative atrial fibrillation after thoracic surgery. Eur J Cardiothorac Surg 2021; 57:874-880. [PMID: 31845993 DOI: 10.1093/ejcts/ezz341] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/06/2019] [Accepted: 11/13/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES A prediction model developed by Passman et al. stratifies patients' risk of postoperative atrial fibrillation (POAF) after major non-cardiac thoracic surgery using 3 simple factors (sex, age and preoperative resting heart rate). The model has neither undergone external validation nor proven to be relevant in current thoracic surgery practice. METHODS A retrospective single-centre analysis of all patients who underwent major non-cardiac thoracic surgery (2008-2017) with prospective documentation of incidence and severity of POAF was used for external validation of Passman's derivation sample (published in 2005 with 856 patients). The model calibration was assessed by evaluating the incidence of POAF and patients' risk scores (0-6). RESULTS A total of 2054 patients were included. Among them, POAF occurred in 164 (7.9%), compared to 147 (17.2%) in Passman's study. Differences in our sample compared to Passman's sample included mean heart rate (75.7 vs 73.7 bpm, P < 0.001), proportion of patients with hypertension (46.1 vs 29.4%, P < 0.001), proportion of extensive lung resections, particularly pneumonectomy (6.1 vs 21%, P < 0.001) and proportion of minimally invasive surgeries (56.6% vs 0%). The model demonstrated a positive correlation between risk scores and POAF incidence (risk score 1.2% vs 6.16%). CONCLUSIONS The POAF model demonstrated good calibration in our population, despite a lower overall incidence of POAF compared to the derivation study. POAF rates were higher among patients with a higher risk score and undergoing procedures with greater intrathoracic dissection. This tool may be useful in identifying patients who are at risk of POAF when undergoing major thoracic surgery and may, therefore, benefit from targeted prophylactic therapy.
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Affiliation(s)
- Heather Smith
- Division of General Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Heidi Li
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Olivier Brandts-Longtin
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Ching Yeung
- Division of Thoracic Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Donna Maziak
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Division of Thoracic Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Sudhir Sundaresan
- Division of Thoracic Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Rod Passman
- Division of Cardiology, Department of Medicine and Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Farid Shamji
- Division of Thoracic Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Andrew J E Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Division of Thoracic Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
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Affiliation(s)
- Rod Passman
- Northwestern University Feinberg School of Medicine, Center for Arrhythmia Research, Bluhm Cardiovascular Institute, Chicago, IL
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Ma L, Yerly J, Di Sopra L, Piccini D, Lee J, DiCarlo A, Passman R, Greenland P, Kim D, Stuber M, Markl M. Using 5D flow MRI to decode the effects of rhythm on left atrial 3D flow dynamics in patients with atrial fibrillation. Magn Reson Med 2021; 85:3125-3139. [PMID: 33400296 PMCID: PMC7904609 DOI: 10.1002/mrm.28642] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 01/05/2023]
Abstract
PURPOSE This study used a 5D flow framework to explore the influence of arrhythmia on thrombogenic hemodynamic parameters in patients with atrial fibrillation (AF). METHODS A fully self-gated, 3D radial, highly accelerated free-running 5D flow sequence with interleaved four-point velocity-encoding was acquired using an in vitro arrhythmic flow phantom and in 25 patients with a history of AF (68 ± 8 y, 6 female). Self-gating signals were used to calculate AF burden, bin data, and tag each k-space line with its RRLength . Data were binned as an RR-resolved dataset with four RR-interval bins (RR1-RR4, short-to-long) for compressed sensing reconstruction. AF burden was calculated as interquartile range of all intrascan RR-intervals divided by median RR-interval, and left atrial (LA) stasis as the percent of the cardiac cycle where the velocity was <0.1 m/s. RESULTS In vitro results demonstrated successful recovery of RR-binned flow curves using RR-resolved 5D flow compared to a real-time PC reference standard. In vivo, 5D flow was acquired in 8:48 minutes. AF burden was significantly correlated with 5D flow-derived peak (PV) and mean (MV) velocity and stasis (|ρ| = 0.54-0.75, P < .001). Sensitivity analyses determined a threshold for low versus high AF burden at 9.7%. High burden patients had increased LA mean stasis (up to +42%, P < .01), and lower MV and PV (-30%, -40.6%, respectively, P < .01). RR4 deviated furthest from respiratory-resolved reconstruction (end-expiration) with increased mean stasis (7.6% ± 14.0%, P = .10) and decreased PV (-12.7 ± 14.2%, P = .09). CONCLUSIONS RR-resolved 5D flow can capture temporal and RR-resolved 3D hemodynamics in <10 minutes and offers a novel approach to investigate arrhythmias.
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Affiliation(s)
- Liliana Ma
- Department of Radiology, Feinberg School of Medicine, Chicago, IL, USA
- Department of Biomedical Engineering, Northwestern University, Evanston, IL, USA
| | - Jérôme Yerly
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Switzerland
- Center for Biomedical Imaging (CIBM), Lausanne, Switzerland
| | - Lorenzo Di Sopra
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Switzerland
| | - Davide Piccini
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Switzerland
- Advanced Clinical Imaging Technology, Siemens Healthcare AG, Lausanne, Switzerland
| | - Jeesoo Lee
- Department of Radiology, Feinberg School of Medicine, Chicago, IL, USA
| | - Amanda DiCarlo
- Department of Radiology, Feinberg School of Medicine, Chicago, IL, USA
| | - Rod Passman
- Department of Medicine and Preventive Medicine, Feinberg School of Medicine, Chicago, IL, USA
| | - Philip Greenland
- Department of Medicine and Preventive Medicine, Feinberg School of Medicine, Chicago, IL, USA
| | - Daniel Kim
- Department of Radiology, Feinberg School of Medicine, Chicago, IL, USA
- Department of Biomedical Engineering, Northwestern University, Evanston, IL, USA
| | - Matthias Stuber
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Switzerland
- Center for Biomedical Imaging (CIBM), Lausanne, Switzerland
| | - Michael Markl
- Department of Radiology, Feinberg School of Medicine, Chicago, IL, USA
- Department of Biomedical Engineering, Northwestern University, Evanston, IL, USA
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Simons H, Passman R, Sueyoshi K. SOCIAL SCIENCE ORAL ABSTRACTS. Contraception 2021. [DOI: 10.1016/j.contraception.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Varma N, Cygankiewicz I, Turakhia MP, Heidbuchel H, Hu YF, Chen LY, Couderc JP, Cronin EM, Estep JD, Grieten L, Lane DA, Mehra R, Page A, Passman R, Piccini JP, Piotrowicz E, Piotrowicz R, Platonov PG, Ribeiro AL, Rich RE, Russo AM, Slotwiner D, Steinberg JS, Svennberg E. 2021 ISHNE/HRS/EHRA/APHRS Expert Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society. Circ Arrhythm Electrophysiol 2021; 14:e009204. [PMID: 33573393 PMCID: PMC7892205 DOI: 10.1161/circep.120.009204] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Supplemental Digital Content is available in the text. This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society describes the current status of mobile health technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mobile health. The promises of predictive analytics but also operational challenges in embedding mobile health into routine clinical care are explored.
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Affiliation(s)
- Niraj Varma
- Cleveland Clinic, OH (N.V., J.D.E., R.M., R.E.R.)
| | | | | | | | - Yu-Feng Hu
- Taipei Veterans General Hospital, Taiwan (Y.-F.H.)
| | | | | | | | | | | | | | - Reena Mehra
- Cleveland Clinic, OH (N.V., J.D.E., R.M., R.E.R.)
| | - Alex Page
- University of Rochester, NY (J.-P.C., A.P., J.S.S.)
| | - Rod Passman
- Northwestern University Feinberg School of Medicine, Chicago, IL (R. Passman)
| | | | - Ewa Piotrowicz
- National Institute of Cardiology, Warsaw, Poland (E.P., R. Piotrowicz)
| | | | | | - Antonio Luiz Ribeiro
- Faculdade de Medicina, Centro de Telessaúde, Hospital das Clínicas, and Departamento de Clínica Médica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (A.L.R.)
| | | | - Andrea M Russo
- Cooper Medical School of Rowan University, Camden, NJ (A.M.R.)
| | - David Slotwiner
- Cardiology Division, New York-Presbyterian Queens, NY (D.S.)
| | | | - Emma Svennberg
- Karolinska University Hospital, Stockholm, Sweden (E.S.)
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39
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Varma N, Cygankiewicz I, Turakhia M, Heidbuchel H, Hu Y, Chen LY, Couderc JP, Cronin EM, Estep JD, Grieten L, Lane DA, Mehra R, Page A, Passman R, Piccini J, Piotrowicz E, Piotrowicz R, Platonov PG, Ribeiro AL, Rich RE, Russo AM, Slotwiner D, Steinberg JS, Svennberg E. 2021 ISHNE/ HRS/ EHRA/ APHRS collaborative statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society. Ann Noninvasive Electrocardiol 2021; 26:e12795. [PMID: 33513268 PMCID: PMC7935104 DOI: 10.1111/anec.12795] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 02/06/2023] Open
Abstract
This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/ Heart Rhythm Society/ European Heart Rhythm Association/ Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self‐management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.
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Affiliation(s)
| | | | | | - Hein Heidbuchel
- Antwerp University and University Hospital, Antwerp, Belgium
| | - Yufeng Hu
- Taipei Veterans General Hospital, Taipei, Taiwan
| | | | | | | | | | | | | | | | - Alex Page
- University of Rochester, Rochester, NY, USA
| | - Rod Passman
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | | | - Antonio Luiz Ribeiro
- Faculdade de Medicina, Centro de Telessaúde, Hospital das Clínicas, and Departamento de Clínica Médica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Andrea M Russo
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - David Slotwiner
- Cardiology Division, NewYork-Presbyterian Queens, and School of Health Policy and Research, Weill Cornell Medicine, New York, NY, USA
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40
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Varma N, Cygankiewicz I, Turakhia M, Heidbuchel H, Hu Y, Chen LY, Couderc JP, Cronin EM, Estep JD, Grieten L, Lane DA, Mehra R, Page A, Passman R, Piccini J, Piotrowicz E, Piotrowicz R, Platonov PG, Ribeiro AL, Rich RE, Russo AM, Slotwiner D, Steinberg JS, Svennberg E. 2021 ISHNE/HRS/EHRA/APHRS collaborative statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society. J Arrhythm 2021; 37:271-319. [PMID: 33850572 PMCID: PMC8022003 DOI: 10.1002/joa3.12461] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 02/06/2023] Open
Abstract
This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society describes the current status of mobile health (“mHealth”) technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self‐management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.
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Affiliation(s)
| | | | | | | | - Yufeng Hu
- Taipei Veterans General Hospital Taipei Taiwan
| | | | | | | | | | | | | | | | - Alex Page
- University of Rochester Rochester NY USA
| | - Rod Passman
- Northwestern University Feinberg School of Medicine Chicago IL USA
| | | | | | | | | | - Antonio Luiz Ribeiro
- Faculdade de Medicina Centro de Telessaúde Hospital das Clínicas and Departamento de Clínica Médica Universidade Federal de Minas Gerais Belo Horizonte Brazil
| | | | | | - David Slotwiner
- Cardiology Division NewYork-Presbyterian Queens and School of Health Policy and Research Weill Cornell Medicine New York NY USA
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Varma N, Cygankiewicz I, Turakhia M, Heidbuchel H, Hu Y, Chen LY, Couderc J, Cronin EM, Estep JD, Grieten L, Lane DA, Mehra R, Page A, Passman R, Piccini J, Piotrowicz E, Piotrowicz R, Platonov PG, Ribeiro AL, Rich RE, Russo AM, Slotwiner D, Steinberg JS, Svennberg E. 2021 ISHNE / HRS / EHRA / APHRS Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology / Heart Rhythm Society / European Heart Rhythm Association / Asia Pacific Heart Rhythm Society. Eur Heart J Digit Health 2021; 2:7-48. [PMID: 36711170 PMCID: PMC9708018 DOI: 10.1093/ehjdh/ztab001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology / Heart Rhythm Society / European Heart Rhythm Association / Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.
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Affiliation(s)
- Niraj Varma
- Cleveland Clinic, Cleveland, OH, USA,Correspondence: Niraj Varma, Cleveland Clinic, Cleveland, OH, USA.
| | | | | | - Hein Heidbuchel
- Antwerp University and University Hospital, Antwerp, Belgium
| | - Yufeng Hu
- Taipei Veterans General Hospital, Taipei, Taiwan
| | | | | | | | | | | | | | | | - Alex Page
- University of Rochester, Rochester, NY, USA
| | - Rod Passman
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | | | - Antonio Luiz Ribeiro
- Faculdade de Medicina, Centro de Telessaúde, Hospital das Clínicas, and Departamento de Clínica Médica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Andrea M Russo
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - David Slotwiner
- Cardiology Division, NewYork-Presbyterian Queens, and School of Health, Policy and Research, Weill Cornell Medicine, New York, NY, USA
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Lohrmann G, Passman R. The future of long-term monitoring following catheter and surgical intervention for atrial fibrillation. J Cardiovasc Electrophysiol 2020; 32:2808-2812. [PMID: 33345321 DOI: 10.1111/jce.14847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/07/2020] [Indexed: 11/30/2022]
Abstract
Monitoring following catheter or surgical ablation for atrial fibrillation (AF) is an essential tool used to assess outcomes for research purposes and help guide clinical decision making. The most commonly used methods to monitor for postintervention AF include a variety of ambulatory external electrocardiogram monitors, cardiac implantable electronic devices, and more recently, direct to consumer digital health technologies. The traditional metric of ablation success, recurrence > 30 s at 1 year, is below the detection capabilities of almost all monitoring techniques yet still undervalues the efficacy of AF interventions. Measures of AF burden reduction and duration give a more complete assessment of the impact of AF surgeries and ablation. As it is increasingly being recognized that AF burden and duration is related to stroke risk, long-term, inexpensive, noninvasive monitoring methods are needed. Smart phones and watches with AF-detecting capabilities, which are increasingly being used by the majority of U.S. adults, have emerged as viable options to achieve this goal, shifting the paradigm of AF monitoring to a more patient-centered approach.
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Affiliation(s)
- Graham Lohrmann
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Rod Passman
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois, USA.,Northwestern University Center for Arrhythmia Research, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Goldberger JJ, Green D, Ringwala S, Andrei AC, Xu Y, Passman R. Left and Right Atrial Biomarker Analysis in Atrial Fibrillation. JACC Clin Electrophysiol 2020; 6:1571-1572. [PMID: 33213817 DOI: 10.1016/j.jacep.2020.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/05/2020] [Accepted: 06/09/2020] [Indexed: 11/13/2022]
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Tarakji KG, Silva J, Chen LY, Turakhia MP, Perez M, Attia ZI, Passman R, Boissy A, Cho DJ, Majmudar M, Mehta N, Wan EY, Chung M. Digital Health and the Care of the Patient With Arrhythmia. Circ Arrhythm Electrophysiol 2020; 13:e007953. [DOI: 10.1161/circep.120.007953] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The field of cardiac electrophysiology has been on the cutting edge of advanced digital technologies for many years. More recently, medical device development through traditional clinical trials has been supplemented by direct to consumer products with advancement of wearables and health care apps. The rapid growth of innovation along with the mega-data generated has created challenges and opportunities. This review summarizes the regulatory landscape, applications to clinical practice, opportunities for virtual clinical trials, the use of artificial intelligence to streamline and interpret data, and integration into the electronic medical records and medical practice. Preparation of the new generation of physicians, guidance and promotion by professional societies, and advancement of research in the interpretation and application of big data and the impact of digital technologies on health outcomes will help to advance the adoption and the future of digital health care.
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Affiliation(s)
- Khaldoun G. Tarakji
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute (K.G.T., M.C.), Cleveland Clinic, OH
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH (K.G.T., N.M., M.C.)
| | - Jennifer Silva
- Division of Pediatric Cardiology, Department of Pediatrics, Washington University in St Louis, MO (J.S.)
| | - Lin Y. Chen
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis (L.Y.C.)
| | - Mintu P. Turakhia
- Ctr for Digital Health, Stanford University, Stanford and Veterans Affairs Palo Alto Health Care System, CA (M.P.T., M.P.)
| | | | - Zachi I. Attia
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (Z.I.A.)
| | - Rod Passman
- Center for Arrhythmia Research, Northwestern University Feinberg School of Medicine, Chicago, IL (R.P.)
| | - Adrienne Boissy
- Office of Patient Experience and Neurological Institute (A.B.), Cleveland Clinic, OH
| | - David J. Cho
- Division of Cardiovascular Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA (D.J.C.)
| | | | - Neil Mehta
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH (K.G.T., N.M., M.C.)
| | - Elaine Y. Wan
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York (E.Y.W.)
| | - Mina Chung
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute (K.G.T., M.C.), Cleveland Clinic, OH
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute (M.C.), Cleveland Clinic, OH
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH (K.G.T., N.M., M.C.)
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Singer D, Ziegler P, Koehler J, Sarkar S, Passman R. Temporal relationship between atrial fibrillation and ischaemic stroke in a large cohort with continuous rhythm monitoring. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background/Introduction
Atrial fibrillation (AF) increases the risk of ischaemic stroke, but the temporal relationship is uncertain.
Purpose
To assess the temporal relationship between AF episodes and ischaemic stroke in patients with cardiovascular implantable electronic devices (CIED) utilizing a case-crossover analysis.
Methods
We linked a very large U.S. aggregated de-identified electronic health record database (2007–2017), containing claims for ischaemic stroke hospitalizations, to a manufacturer's CIED database with continuous AF monitoring. All stroke patients with ≥120 days of pre-stroke rhythm data were included. For each stroke patient, we compared the presence of a day with ≥5.5 hours of AF (the TRENDS study threshold) in the case period (days 1–30 pre-stroke) to that in the control period (days 91–120 pre-stroke). Matched analyses for dichotomous outcomes generated odds ratios with confidence intervals and p values.
Results
We identified 891 ischaemic stroke patients (71.3±10.5 years, 65% male, 27% pacemakers, 60% defibrillators, 13% insertable cardiac monitors) with continuous monitoring data in the 120 days pre-stroke. The vast majority had either no AF in both the case and control periods (n=682, 77%) or AF in both periods (n=143, 16%), i.e., non-informative records. However, among the 66 patients with informative, discordant arrhythmic states, 52 had AF in the case period versus 14 in the control period, for an odds ratio of 3.71 (95% C.I. 2.06–6.70, p<0.001). Analysed by 5-day periods, stroke risk was markedly increased within 30 days of the AF episode (figure). For days 1–5 following an AF episode, the odds ratio was 9.7 (95% C.I. 5.9–16.1). Risk diminished towards non-AF risk after 30 days.
Conclusion
Our analysis of this largest cohort with continuous rhythm monitoring prior to ischaemic stroke demonstrates that stroke risk is highest within a few days of an episode of AF and diminishes rapidly thereafter. Our findings support a strategy of time-limited anticoagulation for patients with infrequent episodes of AF and available continuous rhythm monitoring.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- D Singer
- Massachusetts General Hospital, Division of General Internal Medicine, Department of Medicine, Boston, United States of America
| | - P.D Ziegler
- Medtronic, Inc., Minneapolis, United States of America
| | - J Koehler
- Medtronic, Inc., Minneapolis, United States of America
| | - S Sarkar
- Medtronic, Inc., Minneapolis, United States of America
| | - R Passman
- Northwestern University, Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Chicago, United States of America
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Zweibel S, Passman R, Sarkar S, Koehler J, Ziegler P. Are all CHA2DS2-VASc risk factors created equal? An assessment of stroke risk among 34,470 patients with CHA2DS2-VASc scores of 1 or 2. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
The CHA2DS2-VASc score is commonly used to assess ischemic stroke risk in patients with documented atrial fibrillation (AF). Whether each combination of CHA2DS2-VASc score 1 or 2 confers a similar stroke risk is poorly understood.
Methods
A de-identified database of aggregated electronic health record (EHR) data from 2007–2017 was used to identify patients not on oral anticoagulation (OAC) who had documented AF and CHA2DS2-VASc scores of 1 or 2. CHA2DS2-VASc=1 groups included patients with only heart failure, hypertension, age 65–74, diabetes, vascular disease or female gender. The 17 possible permutations of CHA2DS2-VASc =2 scores were consolidated into 6 groups: prior stroke/TIA, age >75, 2 co-morbidities, 1 co-morbidity + age 65–74, 1 co-morbidity + female gender, or age 65–74 + female gender. Stroke risk hazard ratios were computed for each of these groups.
Results
A total of 34,470 patients (61.0±12.0 years, 67.3% male) not on OAC with a documented history of AF and CHA2DS2-VASc scores of 1 (n=16,572) or 2 (n=17,898) were identified. The annual risks of ischemic stroke among CHA2DS2-VASc 1 and 2 patients were 0.22% [0.18–0.26] and 0.38% [0.33–0.43], respectively. For CHA2DS2-VASc =1 patients, age 65–74 conferred a greater risk of stroke while female gender conferred a lower risk. For CHA2DS2-VASc =2 patients, prior stroke/TIA conferred a greater risk of stroke while 1 co-morbidity + female gender conferred a lower risk [Figure].
Conclusion
Ischemic stroke risk varies significantly across specific risk factors in patients with CHA2DS2-VASc scores =1 or 2. Therefore, OAC decisions in these patients should consider individual risk factors rather than the aggregate score alone.
Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): Medtronic
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Affiliation(s)
- S Zweibel
- Hartford Hospital, Hartford, United States of America
| | - R Passman
- Northwestern University, Cardiology, Chicago, United States of America
| | - S Sarkar
- Medtronic Inc., Minneapolis, United States of America
| | - J Koehler
- Medtronic Inc., Minneapolis, United States of America
| | - P Ziegler
- Medtronic Inc., Minneapolis, United States of America
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Lohrmann G, Kaplan R, Ziegler PD, Monteiro J, Passman R. Atrial fibrillation ablation success defined by duration of recurrence on cardiac implantable electronic devices. J Cardiovasc Electrophysiol 2020; 31:3124-3131. [PMID: 33079437 DOI: 10.1111/jce.14781] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/08/2020] [Accepted: 10/14/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Ablation for atrial fibrillation (AF) has emerged as an effective method of rhythm control. This exploratory analysis aimed to determine how various measures of recurrence would influence the definition of treatment success. METHODS Using an electronic health record data set from January 2007 to June 2019 linked with Medtronic cardiac implantable electronic device (CIED) data, patients who underwent a first AF ablation procedure following CIED implantation were identified. Data were analyzed for recurrence of AF stratified by varying definitions of successful ablation. The performance of various simulated external AF monitoring strategies was assessed. RESULTS A total of 665 patients were analyzed including 248 with paroxysmal AF (mean age: 66.2 ± 9.3 years, 73.0% male) and 417 patients with persistent AF (mean age: 67.3 ± 9.0 years, 73.6% male). Among patients with paroxysmal AF, survival free from recurrence at 1 year ranged from 28.2% to 72.1% (>6 min and >23 h thresholds, respectively) with an overall median percentage of time in AF reduction of 99.6%. Among patients with persistent AF, survival free from recurrence at 1 year ranged from 24.9% to 60.0% (>6 min and 7 consecutive days > 23 h thresholds, respectively) with an overall median percentage of time in AF reduction of 99.3%. A single 7-day monitoring strategy had a sensitivity of less than 50% for detecting AF greater than 6 min in patients with paroxysmal and persistent AF. CONCLUSION In this real-world data set of AF patients with CIEDs undergoing catheter ablation, treatment success varied substantially with different definitions of minimally required AF duration and is significantly impacted by the method of recurrence detection.
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Affiliation(s)
- Graham Lohrmann
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Rachel Kaplan
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | | | - Rod Passman
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois, USA.,Northwestern University Center for Arrhythmia Research, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Yoo S, Pfenniger A, Hoffman J, Zhang W, Ng J, Burrell A, Johnson DA, Gussak G, Waugh T, Bull S, Benefield B, Knight BP, Passman R, Wasserstrom JA, Aistrup GL, Arora R. Attenuation of Oxidative Injury With Targeted Expression of NADPH Oxidase 2 Short Hairpin RNA Prevents Onset and Maintenance of Electrical Remodeling in the Canine Atrium: A Novel Gene Therapy Approach to Atrial Fibrillation. Circulation 2020; 142:1261-1278. [PMID: 32686471 PMCID: PMC9277750 DOI: 10.1161/circulationaha.119.044127] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common heart rhythm disorder in adults and a major cause of stroke. Unfortunately, current treatments of AF are suboptimal because they are not targeted to the molecular mechanisms underlying AF. Using a highly novel gene therapy approach in a canine, rapid atrial pacing model of AF, we demonstrate that NADPH oxidase 2 (NOX2) generated oxidative injury causes upregulation of a constitutively active form of acetylcholine-dependent K+ current (IKACh), called IKH; this is an important mechanism underlying not only the genesis, but also the perpetuation of electric remodeling in the intact, fibrillating atrium. METHODS To understand the mechanism by which oxidative injury promotes the genesis and maintenance of AF, we performed targeted injection of NOX2 short hairpin RNA (followed by electroporation to facilitate gene delivery) in atria of healthy dogs followed by rapid atrial pacing. We used in vivo high-density electric mapping, isolation of atrial myocytes, whole-cell patch clamping, in vitro tachypacing of atrial myocytes, lucigenin chemiluminescence assay, immunoblotting, real-time polymerase chain reaction, immunohistochemistry, and Masson trichrome staining. RESULTS First, we demonstrate that generation of oxidative injury in atrial myocytes is a frequency-dependent process, with rapid pacing in canine atrial myocytes inducing oxidative injury through the induction of NOX2 and the generation of mitochondrial reactive oxygen species. We show that oxidative injury likely contributes to electric remodeling in AF by upregulating IKACh by a mechanism involving frequency-dependent activation of PKCε (protein kinase C epsilon). The time to onset of nonsustained AF increased by >5-fold in NOX2 short hairpin RNA-treated dogs. Furthermore, animals treated with NOX2 short hairpin RNA did not develop sustained AF for up to 12 weeks. The electrophysiological mechanism underlying AF prevention was prolongation of atrial effective refractory periods, at least in part attributable to the attenuation of IKACh. Attenuated membrane translocation of PKCε appeared to be a likely molecular mechanism underlying this beneficial electrophysiological remodeling. CONCLUSIONS NOX2 oxidative injury (1) underlies the onset, and the maintenance of electric remodeling in AF, as well, and (2) can be successfully prevented with a novel, gene-based approach. Future optimization of this approach may lead to a novel, mechanism-guided therapy for AF.
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Affiliation(s)
- Shin Yoo
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Anna Pfenniger
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jacob Hoffman
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Wenwei Zhang
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jason Ng
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Amy Burrell
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - David A. Johnson
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Georg Gussak
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Trent Waugh
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Suzanne Bull
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Brandon Benefield
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Bradley P. Knight
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Rod Passman
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - J. Andrew Wasserstrom
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Rishi Arora
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
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Gunasekaran S, Lee DC, Knight BP, Fan L, Collins JD, Chow K, Carr JC, Passman R, Kim D. Left Ventricular Extracellular Volume Expansion Is Not Associated with Atrial Fibrillation or Atrial Fibrillation-mediated Left Ventricular Systolic Dysfunction. Radiol Cardiothorac Imaging 2020; 2:e190096. [PMID: 32420547 PMCID: PMC7208181 DOI: 10.1148/ryct.2020190096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 09/26/2019] [Accepted: 10/08/2019] [Indexed: 05/02/2023]
Abstract
PURPOSE To determine whether left ventricular (LV) extracellular volume (ECV) expansion is associated with atrial fibrillation (AF) or AF-mediated LV systolic dysfunction (LVSD) while minimizing the influence of biologic and imaging methodologic confounders. MATERIALS AND METHODS This study examined the prevalence of LV ECV expansion in 137 patients with AF (mean age, 62 years ± 11 [standard deviation]; 92 male patients and 45 female patients; 83 paroxysmal and 54 persistent) who underwent preablation cardiovascular MRI. Biologic confounders were minimized by measuring the ECV fraction and excluding patients with severe LV hypertrophy, defined as wall thickness greater than 1.5 cm. Imaging confounders were minimized by using an arrhythmia-insensitive-rapid (AIR) cardiac T1 mapping pulse sequence. Other cardiac functional parameters, including LV ejection fraction (LVEF) and left atrial end-diastolic volume indexed to body surface area, were assessed using cine cardiovascular MRI. A substudy was conducted in 32 patients with no AF (mean age, 54 years ± 16) in sinus rhythm to establish control values and convert these values between the AIR sequence and literature-based modified Look-Locker inversion recovery (MOLLI) values. RESULTS The mean ECV was not significantly different (P > .05) between patients with AF with a normal LVEF (24.5% ± 2.8; n = 107), patients with AF with LVSD (24.5% ± 2.5; n = 30), and patients with no AF (24.4% ± 3.8; n = 32), but there was a significant interaction between ECV and CHA2DS2-VASc score (P = .045). Compared with the literature data obtained from healthy control patients scanned using MOLLI, 99.3% of patients with AF had ECV below the fibrosis cutoff point (32.8% when converted from MOLLI T1 mapping to AIR T1 mapping), including a subset of patients with AF (n = 28) with low CHA2DS2-VASc score (0/1 for men/women). CONCLUSION Study results suggest that an LV ECV expansion is not associated with AF or AF-mediated LVSD. Supplemental material is available for this article. © RSNA, 2020See also the commentary by Stillman in this issue.
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Affiliation(s)
- Rod Passman
- Northwestern University Feinberg School of Medicine and the Bluhm Cardiovascular Institute, Chicago, IL.
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