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Dong J, Kwan E, Bergquist JA, Steinberg BA, Dosdall DJ, DiBella EVR, MacLeod RS, Bunch TJ, Ranjan R. Ablation-induced left atrial mechanical dysfunction recovers in weeks after ablation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01795-x. [PMID: 38587576 DOI: 10.1007/s10840-024-01795-x] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 03/18/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND The immediate impact of catheter ablation on left atrial mechanical function and the timeline for its recovery in patients undergoing ablation for atrial fibrillation (AF) remain uncertain. The mechanical function response to catheter ablation in patients with different AF types is poorly understood. METHODS A total of 113 AF patients were included in this retrospective study. Each patient had three magnetic resonance imaging (MRI) studies in sinus rhythm: one pre-ablation, one immediate post-ablation (within 2 days after ablation), and one post-ablation follow-up MRI (≤ 3 months). We used feature tracking in the MRI cine images to determine peak longitudinal atrial strain (PLAS). We evaluated the change in strain from pre-ablation, immediately after ablation to post-ablation follow-up in a short-term study (< 50 days) and a 3-month study (3 months after ablation). RESULTS The PLAS exhibited a notable reduction immediately after ablation, compared to both pre-ablation levels and those observed in follow-up studies conducted at short-term (11.1 ± 9.0 days) and 3-month (69.6 ± 39.6 days) intervals. However, there was no difference between follow-up and pre-ablation PLAS. The PLAS returned to 95% pre-ablation level within 10 days. Paroxysmal AF patients had significantly higher pre-ablation PLAS than persistent AF patients in pre-ablation MRIs. Both type AF patients had significantly lower immediate post-ablation PLAS compared with pre-ablation and post-ablation PLAS. CONCLUSION The present study suggested a significant drop in PLAS immediately after ablation. Left atrial mechanical function recovered within 10 days after ablation. The drop in PLAS did not show a substantial difference between paroxysmal and persistent AF patients.
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Affiliation(s)
- Jiawei Dong
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Eugene Kwan
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Jake A Bergquist
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, USA
| | - Benjamin A Steinberg
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Derek J Dosdall
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University fo Utah, Salt Lake City, UT, USA
| | - Edward V R DiBella
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
- Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Rob S MacLeod
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, USA
| | - T Jared Bunch
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Ravi Ranjan
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA.
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA.
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA.
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Ahmed B, Bunch TJ. Editorial commentary: Adiposity, altered inflammatory pathways, and atrial fibrillation: Mechanistic links or an epiphenomenon? Trends Cardiovasc Med 2024; 34:159-160. [PMID: 36669546 DOI: 10.1016/j.tcm.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/19/2023]
Affiliation(s)
- Bilal Ahmed
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah, United States
| | - T Jared Bunch
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah, United States.
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Deering TF, Bunch TJ, Lakkireddy D, Liu CF, Piccini JP, Smith AM. Pulsed field ablation: A promise with future broad-based applicability or a pause needing further analysis-Is catheter ablation at a crossroads? A critical appraisal of the new challenger-pulsed field ablation. Heart Rhythm 2024:S1547-5271(24)02256-2. [PMID: 38548125 DOI: 10.1016/j.hrthm.2024.03.1763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 03/19/2024] [Accepted: 03/22/2024] [Indexed: 04/17/2024]
Affiliation(s)
| | - T Jared Bunch
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
| | | | | | - Jonathan P Piccini
- Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina
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4
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Bunch TJ. Pulsed Field Ablation for Paroxysmal Atrial Fibrillation. Reply. N Engl J Med 2024; 390:1056. [PMID: 38478000 DOI: 10.1056/nejmc2313783] [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: 03/14/2024]
Affiliation(s)
- T Jared Bunch
- University of Utah Health Sciences Center, Salt Lake City, UT
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5
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Steinberg BA, Holubkov R, Deering T, Groh CA, Mittal S, Kennedy R, Pokharel P, Perez M, Savona S, Verma N, Watt K, Piccini JP, Bunch TJ. Expedited loading with intravenous sotalol is safe and feasible-primary results of the Prospective Evaluation Analysis and Kinetics of IV Sotalol (PEAKS) Registry. Heart Rhythm 2024:S1547-5271(24)00218-2. [PMID: 38417598 DOI: 10.1016/j.hrthm.2024.02.046] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Loading of oral sotalol for atrial fibrillation requires 3 days, frequently in the hospital, to achieve steady state. The Food and Drug Administration approved loading with intravenous (IV) sotalol through model-informed development, without patient data. OBJECTIVE We present results of the first multicenter evaluation of this recent labeling for IV sotalol. METHODS The Prospective Evaluation Analysis and Kinetics of IV Sotalol (PEAKS) Registry was a multicenter observational registry of patients undergoing elective IV sotalol load for atrial arrhythmias. Outcomes, measured from hospital admission until first outpatient follow-up, included adverse arrhythmia events, efficacy, and length of stay. RESULTS Of 167 consecutively enrolled patients, 23% were female; the median age was 68 (interquartile range, 61-74) years, and the median CHA2DS2-VASc score was 3 (interquartile range, 2-4). Overall, 99% were admitted for sotalol initiation (1% for dose escalation), with a target oral sotalol dose of either 80 mg twice daily (85 [51%]) or 120 mg twice daily (78 [47%]); 62 patients (37%) had an estimated creatinine clearance ≤90 mL/min. On presentation, 40% of patients were in sinus rhythm, whereas 26% underwent cardioversion before sotalol infusion. In 2 patients, sotalol infusion was stopped for bradycardia or hypotension. In 6 patients, sotalol was discontinued before discharge because of QTc prolongation (3), bradycardia (1), or recurrent atrial arrhythmia (2). The mean length of stay was 1.1 days, and 95% (n = 159) were discharged within 1 night. CONCLUSION IV sotalol loading is safe and feasible for atrial arrhythmias, with low rates of adverse events, and yields shorter hospitalizations. More data are needed on the minimal duration required for monitoring in the hospital.
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Affiliation(s)
- Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, Utah.
| | - Richard Holubkov
- Data Coordinating Center, Department of Pediatrics, Spencer Eccles Fox School of Medicine, University of Utah, Salt Lake City, Utah
| | | | - Christopher A Groh
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, Utah
| | | | | | | | - Marco Perez
- Department of Medicine, Stanford University, Stanford, California
| | - Salvatore Savona
- Department of Medicine, The Ohio State University, Columbus, Ohio
| | - Nishant Verma
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kevin Watt
- Division of Clinical Pharmacology, Department of Pediatrics, Spencer Eccles Fox School of Medicine, University of Utah, Salt Lake City, Utah
| | - Jonathan P Piccini
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - T Jared Bunch
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, Utah
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6
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Maclean ES, Bunch TJ, Freedman RA, Piccini JP, Steinberg BA. Leadless pacemaker tine damage and fracture: novel complications of a novel device fixation mechanism. Heart Rhythm O2 2024; 5:17-23. [PMID: 38312201 PMCID: PMC10837171 DOI: 10.1016/j.hroo.2023.11.018] [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] [Indexed: 02/06/2024] Open
Abstract
Background Leadless pacemakers represent a paradigm-changing advancement. However, they required innovative and novel device design, including the use of nitinol tines for fixation. Objective We aimed to understand the potential for fracture in the novel tine-based fixation mechanism. Methods A retrospective approach was used to search the MAUDE (Manufacturer and User Facility Device Experience) database for events related to Micra pacemaker tine fracture and damage. Review of each report was performed to ascertain frequency of tine fracture and damage. Results Of 4241 MAUDE reports (2104 Micra VR, 2167 Micra AV), 230 included the terms "fracture" or "tine," which yielded 7 tine fractures and 19 reports of tine damage. Overall, 2 (29%) of 7 tine fractures were noted during implantation, whereas 2 (29%) of 7 were discovered ≥1 week after implantation; 5 (71%) of 7 tine fracture reports described no associated patient signs or symptoms, and 4 (57%) of 7 described no change in pacing parameters. Tine damage occurred during implantation in 16 (84%) of 19, compared with 2 (11%) of 19 noted ≥1 week after implantation; 15 (79%) of 19 tine damage cases reported no associated signs or symptoms, and 7 (37%) of 19 described no changes in pacing parameters. Among all cases, there was 1 case of device embolization. Conclusion The novel tine-based fixation mechanism appears susceptible to a novel failure mechanism-tine fracture and/or damage. Our analysis suggests these events may not always be associated with adverse signs or symptoms. Diligent attention at implantation, and future bench or clinical studies are needed to understand the rate, clinical impact, and mechanism of such failures, and role of surveillance.
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Affiliation(s)
- Erick S. Maclean
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - T. Jared Bunch
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Roger A. Freedman
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Jonathan P. Piccini
- Duke University Medical Center and the Duke Clinical Research Institute, Durham, North Carolina
| | - Benjamin A. Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
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7
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Bunch TJ. Hope, Hype, and Reality of Pulsed Field Ablation for Atrial Fibrillation. N Engl J Med 2023; 389:1720-1721. [PMID: 37913511 DOI: 10.1056/nejme2309476] [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: 11/03/2023]
Affiliation(s)
- T Jared Bunch
- From the Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City
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8
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Perino AC, Wang PJ, Lloyd M, Zanon F, Fujiu K, Osman F, Briongos-Figuero S, Sato T, Aksu T, Jastrzebski M, Sideris S, Rao P, Boczar K, Yuan-Ning X, Wu M, Namboodiri N, Garcia R, Kataria V, De Pooter J, Przibille O, Gehi AK, Cano O, Katsouras G, Cai B, Astheimer K, Tanawuttiwat T, Datino T, Rizkallah J, Alasti M, Feld G, Barrio-Lopez MT, Gilmore M, Conti S, Yanagisawa S, Indik JH, Zou J, Saha SA, Rodriguez-Munoz D, Chang KC, Lebedev DS, Leal MA, Haeberlin A, Forno ARJD, Orlov M, Frutos M, Cabanas-Grandio P, Lyne J, Leyva F, Tolosana JM, Ollitrault P, Vergara P, Balla C, Devabhaktuni SR, Forleo G, Letsas KP, Verma A, Moak JP, Shelke AB, Curila K, Cronin EM, Futyma P, Wan EY, Lazzerini PE, Bisbal F, Casella M, Turitto G, Rosenthal L, Bunch TJ, Baszko A, Clementy N, Cha YM, Chen HC, Galand V, Schaller R, Jarman JWE, Harada M, Wei Y, Kusano K, Schmidt C, Hurtado MAA, Naksuk N, Hoshiyama T, Kancharla K, Iida Y, Mizobuchi M, Morin DP, Cay S, Paglino G, Dahme T, Agarwal S, Vijayaraman P, Sharma PS. Worldwide survey on implantation of and outcomes for conduction system pacing with His bundle and left bundle branch area pacing leads. J Interv Card Electrophysiol 2023; 66:1589-1600. [PMID: 36607529 PMCID: PMC9817436 DOI: 10.1007/s10840-022-01417-4] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/03/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Adoption and outcomes for conduction system pacing (CSP), which includes His bundle pacing (HBP) or left bundle branch area pacing (LBBAP), in real-world settings are incompletely understood. We sought to describe real-world adoption of CSP lead implantation and subsequent outcomes. METHODS We performed an online cross-sectional survey on the implantation and outcomes associated with CSP, between November 15, 2020, and February 15, 2021. We described survey responses and reported HBP and LBBAP outcomes for bradycardia pacing and cardiac resynchronization CRT indications, separately. RESULTS The analysis cohort included 140 institutions, located on 5 continents, who contributed data to the worldwide survey on CSP. Of these, 127 institutions (90.7%) reported experience implanting CSP leads. CSP and overall device implantation volumes were reported by 84 institutions. In 2019, the median proportion of device implants with CSP, HBP, and/or LBBAP leads attempted were 4.4% (interquartile range [IQR], 1.9-12.5%; range, 0.4-100%), 3.3% (IQR, 1.3-7.1%; range, 0.2-87.0%), and 2.5% (IQR, 0.5-24.0%; range, 0.1-55.6%), respectively. For bradycardia pacing indications, HBP leads, as compared to LBBAP leads, had higher reported implant threshold (median [IQR]: 1.5 V [1.3-2.0 V] vs 0.8 V [0.6-1.0 V], p = 0.0008) and lower ventricular sensing (median [IQR]: 4.0 mV [3.0-5.0 mV] vs. 10.0 mV [7.0-12.0 mV], p < 0.0001). CONCLUSION In conclusion, CSP lead implantation has been broadly adopted but has yet to become the default approach at most surveyed institutions. As the indications and data for CSP continue to evolve, strategies to educate and promote CSP lead implantation at institutions without CSP lead implantation experience would be necessary.
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Affiliation(s)
- Alexander C Perino
- Center for Academic Medicine, Department of Medicine/Division of Cardiovascular Medicine, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA, 94304, USA.
| | - Paul J Wang
- Center for Academic Medicine, Department of Medicine/Division of Cardiovascular Medicine, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA, 94304, USA
| | | | - Francesco Zanon
- Santa Maria Della Misericordia General Hospital, Perugia, Italy
| | | | | | | | | | - Tolga Aksu
- Yeditepe University Hospital, Istanbul, Turkey
| | | | | | - Praveen Rao
- Baylor University Medical Center, Dallas, USA
| | | | - Xu Yuan-Ning
- West China Hospital, Sichuan University, Chengdu, China
| | - Michael Wu
- Lifespan Cardiovascular Institute, Brown University, Providence, USA
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | | | - Anil K Gehi
- University of North Carolina School of Medicine, Chapel Hill, USA
| | - Oscar Cano
- Hospital Universitari I Politècnic La Fe, Valencia, Spain
- Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | | | - Binni Cai
- Xiamen Cardiovascular Hospital, Xiamen, China
| | | | | | - Tomas Datino
- Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | | | | | - Gregory Feld
- University of California San Diego Health System, San Diego, USA
| | | | | | | | | | - Julia H Indik
- University of Arizona College of Medicine, Tucson, USA
| | - Jiangang Zou
- First Affiliated Hospital of Nanjing Medical University, Jiangsu Provincial Hospital, Nanjing, China
| | | | | | - Kuan-Cheng Chang
- School of Medicine, China Medical University, Taichung, Taiwan
- China Medical University Hospital, Taichung, Taiwan
| | - Dmitry S Lebedev
- National Medical Research Center. VA Almazov, Saint Petersburg, Russia
| | - Miguel A Leal
- School of Medicine and Public Health, University of Wisconsin, Madison, USA
| | | | | | | | - Manuel Frutos
- Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | | | - Francisco Leyva
- Aston University, Birmingham, UK
- Queen Elizabeth Hospital, Birmingham, UK
| | | | | | | | - Cristina Balla
- Azienda Ospedaliero Universitaria Di Ferrara, Cona, Italy
| | | | | | | | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Canada
| | | | | | - Karol Curila
- Cardiocenter, 3Rd Faculty of Medicine, Charles University, Prague, Czechia
| | - Edmond M Cronin
- Lewis Katz School of Medicine at, Temple University, Philadelphia, USA
| | - Piotr Futyma
- Medical College, University of Rzeszów, Rzeszów, Poland
- St. Joseph's Heart Rhythm Center, Rzeszów, Poland
| | | | - Pietro Enea Lazzerini
- University of Siena, Siena, Italy
- Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Felipe Bisbal
- University Hospital Germans Trias I Pujol, Barcelona, Spain
| | | | - Gioia Turitto
- New York-Presbyterian Brooklyn Methodist Hospital, New York, NY, USA
| | | | - T Jared Bunch
- University of Utah School of Medicine, Salt Lake City, USA
| | - Artur Baszko
- Poznań University of Medical Sciences, Poznań, Poland
| | | | | | | | | | - Robert Schaller
- Hospital of the University of Pennsylvania, Philadelphia, USA
| | | | | | - Yong Wei
- Shanghai General Hospital, Shanghai, China
| | - Kengo Kusano
- National Cerebral and Cardiovascular Center, Suita, Japan
| | | | | | | | | | | | - Yoji Iida
- Kobari General Hospital, Noda, Japan
| | | | | | | | | | - Tillman Dahme
- Universitätsklinikum Ulm (Ulm University Medical Center), Ulm, Germany
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Bergquist JA, Zenger B, Brundage J, MacLeod RS, Bunch TJ, Shah R, Ye X, Lyons A, Ranjan R, Tasdizen T, Steinberg BA. Performance of Off-the-Shelf Machine Learning Architectures and Biases in Detection of Low Left Ventricular Ejection Fraction. medRxiv 2023:2023.06.10.23291237. [PMID: 37649910 PMCID: PMC10465010 DOI: 10.1101/2023.06.10.23291237] [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: 09/01/2023]
Abstract
Artificial intelligence - machine learning (AI-ML) is a computational technique that has been demonstrated to be able to extract meaningful clinical information from diagnostic data that are not available using either human interpretation or more simple analysis methods. Recent developments have shown that AI-ML approaches applied to ECGs can accurately predict different patient characteristics and pathologies not detectable by expert physician readers. There is an extensive body of literature surrounding the use of AI-ML in other fields, which has given rise to an array of predefined open-source AI-ML architectures which can be translated to new problems in an "off-the-shelf" manner. Applying "off-the-shelf" AI-ML architectures to ECG-based datasets opens the door for rapid development and identification of previously unknown disease biomarkers. Despite the excellent opportunity, the ideal open-source AI-ML architecture for ECG related problems is not known. Furthermore, there has been limited investigation on how and when these AI-ML approaches fail and possible bias or disparities associated with particular network architectures. In this study, we aimed to: (1) determine if open-source, "off-the-shelf" AI-ML architectures could be trained to classify low LVEF from ECGs, (2) assess the accuracy of different AI-ML architectures compared to each other, and (3) to identify which, if any, patient characteristics are associated with poor AI-ML performance.
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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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Zenger B, Li H, Bunch TJ, Crawford C, Fang JC, Groh CA, Hess R, Navaravong L, Ranjan R, Young J, Zhang Y, Steinberg BA. Major drivers of healthcare system costs and cost variability for routine atrial fibrillation ablation. Heart Rhythm O2 2023; 4:251-257. [PMID: 37124552 PMCID: PMC10134392 DOI: 10.1016/j.hroo.2022.12.014] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Catheter ablation is an effective treatment for atrial fibrillation (AF) but incurs significant financial costs to payers. Reducing variability may improve cost effectiveness. Objectives We aimed to measure (1) the components of direct and indirect costs for routine AF ablation procedures, (2) the variability of those costs, and (3) the main factors driving ablation cost variability. Methods Using data from the University of Utah Health Value Driven Outcomes system, we were able to measure direct, inflation-adjusted costs of uncomplicated, routine AF ablation to the healthcare system. Direct costs were considered costs incurred by pharmacy, disposable supplies, patient labs, implants, and other services categories (primarily anesthesia support) and indirect costs were considered within imaging, facility, and electrophysiology lab management categories. Results A total of 910 patients with 1060 outpatient ablation encounters were included from January 1, 2013, to December 31, 2020. Disposable supplies accounted for the largest component of cost with 44.8 ± 9.7%, followed by other services (primarily anesthesia support) with 30.4 ± 7.7% and facility costs with 16.1 ± 5.6%; pharmacy, imaging, and implant costs each contributed <5%. Direct costs were larger than indirect costs (82.4 ± 5.6% vs 17.6 ± 5.6%). Multivariable regression showed that procedure operator was the primary factor associated with AF ablation overall cost (up to 12% differences depending on operator). Conclusions Direct costs and other services (primarily anesthesia) drive the majority costs associated with AF ablations. There is significant variability in costs for these routine, uncomplicated AF ablation procedures. The procedure operator, and not patient characteristic, is the main driver for cost variability.
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Affiliation(s)
- Brian Zenger
- University of Utah School of Medicine, Salt Lake City, Utah
| | - Haojia Li
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah
| | - T. Jared Bunch
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Candice Crawford
- Decision Support, University of Utah Health, Salt Lake City, Utah
| | - James C. Fang
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Christopher A. Groh
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Rachel Hess
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Ravi Ranjan
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Jeff Young
- Decision Support, University of Utah Health, Salt Lake City, Utah
| | - Yue Zhang
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah
| | - Benjamin A. Steinberg
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
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Tokavanich N, Prasitlumkum N, Kewcharoen J, Chokesuwattanaskul R, Phannajit J, Cheungpasitporn W, Akoum N, Ranjan R, Bunch TJ, Navaravong L. Network meta-analysis and systematic review comparing efficacy and safety between very high power short duration, high power short duration, and conventional radiofrequency ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2023; 34:869-879. [PMID: 36691892 DOI: 10.1111/jce.15831] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 12/16/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND High-power short-duration (HPSD) atrial fibrillation (AF) ablation with a power of 40-50 W was proved to be safe and effective. Very high-power short-duration (vHPSD) AF ablation is a novel method using >50 W to obtain more durable AF ablation. This study aimed to evaluate the efficacy and safety of vHPSD ablation compared with HPSD ablation and conventional power ablation. METHODS A literature search for studies that reported AF ablation outcomes, including short-term freedom from atrial arrhythmia, first-pass isolation (FPI) rate, procedure time, and major complications, was conducted utilizing MEDLINE, EMBASE, and Cochrane databases. All relevant studies were included in this analysis. A random-effects model of network meta-analysis and surface under cumulative ranking curve (SUCRA) were used to rank the treatment for all outcomes. RESULTS A total of 29 studies with 9721 patients were included in the analysis. According to the SUCRA analysis, HPSD ablation had the highest probability of maintaining sinus rhythm. Point estimation showed an odds ratio of 1.5 (95% confidence interval [CI]: 1.2-1.9) between HPSD ablation and conventional power ablation and an odds ratio of 1.3 (95% CI: 0.78-2.2) between vHPSD ablation and conventional power ablation. While the odds ratio of FPI between HPSD ablation and conventional power ablation was 3.6 (95% CI: 1.5-8.9), the odds ratio between vHPSD ablation and conventional power ablation was 2.2 (95% CI: 0.61-8.6). The procedure times of vHPSD and HPSD ablations were comparable and, therefore, shorter than that of conventional power ablation. Major complications were low in all techniques. CONCLUSION vHPSD ablation did not yield higher efficacy than HPSD ablation and conventional power ablation. With the safety concern, vHPSD ablation outcomes were comparable with those of other techniques.
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Affiliation(s)
- Nithi Tokavanich
- Sparrow Hospital, Michigan State University, East Lansing, Michigan, USA
| | - Narut Prasitlumkum
- Department of Cardiology, University of California Riverside, Riverside, California, USA
| | - Jakrin Kewcharoen
- Division of Cardiovascular Medicine, Loma Linda University Health, Loma Linda, California, USA
| | - Ronpichai Chokesuwattanaskul
- Division of Cardiovascular Medicine, Department of Medicine, Cardiac Center, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jeerath Phannajit
- Division of Clinical Epidemiology and Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Nazem Akoum
- Cardiology Department, University of Washington Medical Center, Seattle, Washington, USA
| | - Ravi Ranjan
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - T Jared Bunch
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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13
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Reddy VY, Exner DV, Doshi R, Tomassoni G, Bunch TJ, Friedman P, Estes NAM, Neužil P, de la Concha JF, Cantillon DJ. 1-Year Outcomes of a Leadless Ventricular Pacemaker: The LEADLESS II (Phase 2) Trial. JACC Clin Electrophysiol 2023:S2405-500X(23)00089-0. [PMID: 36951813 DOI: 10.1016/j.jacep.2023.01.031] [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: 11/16/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 03/24/2023]
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14
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Sessions AJ, May HT, Crandall BG, Day JD, Cutler MJ, Groh CA, Navaravong L, Ranjan R, Steinberg BA, Jared Bunch T. Response to "Delay in AF ablation costs lives". J Cardiovasc Electrophysiol 2023; 34:1094-1095. [PMID: 36864718 DOI: 10.1111/jce.15878] [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] [Received: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 03/04/2023]
Affiliation(s)
| | - Heidi T May
- Department of Cardiology, Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah, USA
| | - Brian G Crandall
- Department of Cardiology, Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah, USA
| | - John D Day
- Department of Cardiology, St. Marks Hospital, Utah, Salt Lake City, USA
| | - Michael J Cutler
- Department of Cardiology, Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah, USA
| | - Christopher A Groh
- Department of Internal Medicine, Division of Cardiology, University Hospital, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Leenapong Navaravong
- Department of Internal Medicine, Division of Cardiology, University Hospital, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ravi Ranjan
- Department of Internal Medicine, Division of Cardiology, University Hospital, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Benjamin A Steinberg
- Department of Internal Medicine, Division of Cardiology, University Hospital, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - T Jared Bunch
- Department of Internal Medicine, Division of Cardiology, University Hospital, University of Utah School of Medicine, Salt Lake City, Utah, USA
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15
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Feuerborn ML, Dechand J, Vadlamudi RS, Torre M, Freedman RA, Groh C, Navaravong L, Ranjan R, Varela D, Bunch TJ, Steinberg BA. Protocol Development and Initial Experience With Intravenous Sotalol Loading for Atrial Arrhythmias. Crit Pathw Cardiol 2023; 22:1-4. [PMID: 36812336 PMCID: PMC9977272 DOI: 10.1097/hpc.0000000000000308] [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] [Indexed: 04/16/2023]
Abstract
BACKGROUND Oral sotalol is a class III antiarrhythmic commonly used for the maintenance of sinus rhythm in patients with atrial fibrillation (AF). Recently, the Food and Drug Administration (FDA) approved the use of IV sotalol loading, based primarily on modeling data for the infusion. We aimed to describe a protocol and experience with IV sotalol loading for elective treatment of adult patients with AF and atrial flutter (AFL). METHODS We present our institutional protocol and retrospective review of initial patients treated with IV sotalol for AF/AFL at the University of Utah Hospital between September 2020 and April 2021. RESULTS Eleven patients received IV sotalol for initial loading or dose escalation. All patients were male, aged 56-88 years (median 69). Mean QT interval (QTc) intervals increased from baseline (mean 384 ms) immediately after infusion of IV sotalol (mean change 42ms), but no patient required discontinuation of the medication. Six patients were discharged after 1 night; 4 patients were discharged after 2 nights; and 1 patient was discharged after 4 nights. Nine patients underwent electrical cardioversion prior to discharge (2 prior to load; 7 post-load on the day of discharge). There were no adverse events during the infusion or within 6 months of discharge. Persistence of therapy was 73% (8 of 11) at mean 9.9 weeks to follow up, with no discontinuations for adverse effects. CONCLUSIONS We employed a streamlined protocol that was successfully implemented to facilitate the use of IV sotalol loading for atrial arrhythmias. Our initial experience suggests feasibility, safety, and tolerability while reducing hospitalization duration. Additional data are needed to augment this experience as IV sotalol use is broadened across different patient populations.
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Affiliation(s)
- Melissa L Feuerborn
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - John Dechand
- Department of Pharmacy Services, University of Utah Health, Salt Lake City, UT, USA
| | - Rohith S Vadlamudi
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Michael Torre
- Department of Population Health, University of Utah School of Medicine, Salt Lake City, UT
| | - Roger A. Freedman
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Christopher Groh
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Ravi Ranjan
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Daniel Varela
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - T. Jared Bunch
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Benjamin A. Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
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16
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17
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Scott M, Baykaner T, Bunch TJ, Piccini JP, Russo AM, Tzou WS, Zeitler EP, Steinberg BA. Contemporary trends in cardiac electrophysiology procedures in the United States, and impact of a global pandemic. Heart Rhythm O2 2023; 4:193-199. [PMID: 36569386 PMCID: PMC9767878 DOI: 10.1016/j.hroo.2022.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/12/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Background There are limited data on trends in nationwide cardiac electrophysiology (EP) procedures in the United States before and during the global COVID-19 pandemic. Objective We aimed to understand contemporary EP procedural trends and how the COVID-19 pandemic impacted them. Methods Trends were obtained from publicly reported Centers for Medicare and Medicaid Services data from 2013 to 2020 (latest available). Rates of catheter-based EP procedures (EP studies and ablations) and cardiac implantable electronic device (CIED) procedures were analyzed. All procedural rates were calculated per 100,000 Medicare beneficiaries (year specific). Procedure physician subspecialty was also reported. Results From 2013 to 2019, annual rate of all cardiac EP procedures increased from 817.91 to 1089.68 per 100,000 beneficiaries. Catheter-based EP procedures increased from 323.73 to 675.01, while CIED rates decreased from 494.18 to 414.67. While all ablation procedures increased over time, relative proportion of ablation procedures being pulmonary vein isolation (PVI) increased (9.9% of ablations in 2013, to 18.2% in 2019). In 2020, rates of both catheter-based EP procedures and CIED procedures decreased; however, PVI share of ablation continued to increase in 2020 comprising 25.2% of ablation procedures. Conclusion Rates of EP procedures have increased among Medicare beneficiaries, with catheter-based procedures now eclipsing CIEDs. Additionally, a greater proportion of catheter-based EP procedures are PVI, but they still represent a minority of all ablations. In 2020, rates of EP procedures were attenuated, yet the proportion of PVI ablations increased to over one-fourth of ablation procedures. These data have important implications for the EP workforce.
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Affiliation(s)
- Monte Scott
- Department of Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Tina Baykaner
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - T. Jared Bunch
- Department of Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Jonathan P. Piccini
- Department of Medicine, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina
| | - Andrea M. Russo
- Cooper Medical School of Rowan University, Camden, New Jersey
| | - Wendy S. Tzou
- Department of Medicine, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Emily P. Zeitler
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Benjamin A. Steinberg
- Department of Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
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18
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Wang PJ, Lu Y, Mahaffey KW, Lin A, Morin DP, Sears SF, Chung MK, Russo AM, Lin B, Piccini J, Hills MT, Berube C, Pundi K, Baykaner T, Garay G, Lhamo K, Rice E, Pourshams IA, Shah R, Newswanger P, DeSutter K, Nunes JC, Albert MA, Schulman KA, Heidenreich PA, Bunch TJ, Sanders LM, Turakhia M, Verghese A, Stafford RS. Randomized Clinical Trial to Evaluate an Atrial Fibrillation Stroke Prevention Shared Decision-Making Pathway. J Am Heart Assoc 2023; 12:e028562. [PMID: 36342828 PMCID: PMC9973612 DOI: 10.1161/jaha.122.028562] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Background Oral anticoagulation reduces stroke and disability in atrial fibrillation (AF) but is underused. We evaluated the effects of a novel patient-clinician shared decision-making (SDM) tool in reducing oral anticoagulation patient's decisional conflict as compared with usual care. Methods and Results We designed and evaluated a new digital decision aid in a multicenter, randomized, comparative effectiveness trial, ENHANCE-AF (Engaging Patients to Help Achieve Increased Patient Choice and Engagement for AF Stroke Prevention). The digital AF shared decision-making toolkit was developed using patient-centered design with clear health communication principles (eg, meaningful images, limited text). Available in English and Spanish, the toolkit included the following: (1) a brief animated video; (2) interactive questions with answers; (3) a quiz to check on understanding; (4) a worksheet to be used by the patient during the encounter; and (5) an online guide for clinicians. The study population included English or Spanish speakers with nonvalvular AF and a CHA2DS2-VASc stroke score ≥1 for men or ≥2 for women. Participants were randomized in a 1:1 ratio to either usual care or the shared decision-making toolkit. The primary end point was the validated 16-item Decision Conflict Scale at 1 month. Secondary outcomes included Decision Conflict Scale at 6 months and the 10-item Decision Regret Scale at 1 and 6 months as well as a weighted average of Mann-Whitney U-statistics for both the Decision Conflict Scale and the Decision Regret Scale. A total of 1001 participants were enrolled and followed at 5 different sites in the United States between December 18, 2019, and August 17, 2022. The mean patient age was 69±10 years (40% women, 16.9% Black, 4.5% Hispanic, 3.6% Asian), and 50% of participants had CHA2DS2-VASc scores ≥3 (men) or ≥4 (women). The primary end point at 1 month showed a clinically meaningful reduction in decisional conflict: a 7-point difference in median scores between the 2 arms (16.4 versus 9.4; Mann-Whitney U-statistics=0.550; P=0.007). For the secondary end point of 1-month Decision Regret Scale, the difference in median scores between arms was 5 points in the direction of less decisional regret (P=0.078). The treatment effects lessened over time: at 6 months the difference in medians was 4.7 points for Decision Conflict Scale (P=0.060) and 0 points for Decision Regret Scale (P=0.35). Conclusions Implementation of a novel shared decision-making toolkit (afibguide.com; afibguide.com/clinician) achieved significantly lower decisional conflict compared with usual care in patients with AF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096781.
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Affiliation(s)
- Paul J. Wang
- Stanford University Department of MedicinePalo AltoCA
| | - Ying Lu
- Stanford University Department of Biomedical Data ScienceStanfordCA
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | - Amy Lin
- Stanford University Department of Biomedical Data ScienceStanfordCA
| | | | - Samuel F. Sears
- East Carolina University Department of PsychologyGreenvilleNC
| | - Mina K. Chung
- Cleveland Clinic Foundation Department of MedicineClevelandOH
| | | | - Bryant Lin
- Stanford University Department of MedicinePalo AltoCA
| | | | | | | | - Krishna Pundi
- Stanford University Department of MedicinePalo AltoCA
| | - Tina Baykaner
- Stanford University Department of MedicinePalo AltoCA
| | - Gotzone Garay
- Stanford University Department of MedicinePalo AltoCA
| | - Karma Lhamo
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | - Eli Rice
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | | | - Rushil Shah
- Stanford University Department of MedicinePalo AltoCA
| | - Paul Newswanger
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | | | | | - Michelle A. Albert
- University of California San Francisco Department of MedicineSan FranciscoCA
| | | | - Paul A. Heidenreich
- Stanford University Department of MedicinePalo AltoCA
- Palo Alto Veterans Administration Health Care Department of MedicinePalo AltoCA
| | - T. Jared Bunch
- University of Utah Department of MedicineSalt Lake CityUT
| | | | - Mintu Turakhia
- Stanford University Department of MedicinePalo AltoCA
- iRhythm TechnologiesSan FranciscoCA
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Ahmed B, Bunch TJ. Role of remote monitoring-derived heart rates in the risk stratification of heart failure with reduced ejection fraction: New insights. Heart Rhythm 2023; 20:241-242. [PMID: 36403904 DOI: 10.1016/j.hrthm.2022.11.008] [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] [Received: 11/14/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Bilal Ahmed
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - T Jared Bunch
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah.
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Kamali R, Gillete K, Tate J, Abhyankar DA, Dosdall DJ, Plank G, Bunch TJ, Macleod RS, Ranjan R. Treatment Planning for Atrial Fibrillation Using Patient-Specific Models Showing the Importance of Fibrillatory-Areas. Ann Biomed Eng 2023; 51:329-342. [PMID: 35930093 PMCID: PMC10440744 DOI: 10.1007/s10439-022-03029-5] [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: 01/19/2022] [Accepted: 07/18/2022] [Indexed: 01/25/2023]
Abstract
Computational models have made it possible to study the effect of fibrosis and scar on atrial fibrillation (AF) and plan future personalized treatments. Here, we study the effect of area available for fibrillatory waves to sustain AF. Then we use it to plan for AF ablation to improve procedural outcomes. CARPentry was used to create patient-specific models to determine the association between the size of residual contiguous areas available for AF wavefronts to propagate and sustain AF [fibrillatory area (FA)] after ablation with procedural outcomes. The FA was quantified in a novel manner accounting for gaps in ablation lines. We selected 30 persistent AF patients with known ablation outcomes. We divided the atrial surface into five areas based on ablation scar pattern and anatomical landmarks and calculated the FAs. We validated the models based on clinical outcomes and suggested future ablation lines that minimize the FAs and terminate rotor activities in simulations. We also simulated the effects of three common antiarrhythmic drugs. In the patient-specific models, the predicted arrhythmias matched the clinical outcomes in 25 of 30 patients (accuracy 83.33%). The average largest FA (FAmax) in the recurrence group was 8517 ± 1444 vs. 6772 ± 1531 mm2 in the no recurrence group (p < 0.004). The final FAs after adding the suggested ablation lines in the AF recurrence group reduced the average FAmax from 8517 ± 1444 to 6168 ± 1358 mm2 (p < 0.001) and stopped the sustained rotor activity. Simulations also correctly anticipated the effect of antiarrhythmic drugs in 5 out of 6 patients who used drug therapy post unsuccessful ablation (accuracy 83.33%). Sizes of FAs available for AF wavefronts to propagate are important determinants for ablation outcomes. FA size in combination with computational simulations can be used to direct ablation in persistent AF to minimize the critical mass required to sustain recurrent AF.
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Affiliation(s)
- Roya Kamali
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Karli Gillete
- Institute of Biophysics, Medical University of Graz, Graz, Austria
| | - Jess Tate
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, USA
| | | | - Derek J Dosdall
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
| | - Gernot Plank
- Institute of Biophysics, Medical University of Graz, Graz, Austria
| | - T Jared Bunch
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Rob S Macleod
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
| | - Ravi Ranjan
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA.
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA.
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA.
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22
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Eldadah ZA, Al-Ahmad A, Bunch TJ, Delurgio DB, Doshi RN, Hook BG, Hranitzky PM, Joyner CA, Mittal S, Porterfield C, Sanchez JE, Thambidorai SK, Wazni OM, McElderry HT. Same-day discharge following catheter ablation and venous closure with VASCADE MVP: A postmarket registry. J Cardiovasc Electrophysiol 2023; 34:348-355. [PMID: 36448428 DOI: 10.1111/jce.15763] [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: 09/13/2022] [Revised: 11/08/2022] [Accepted: 11/25/2022] [Indexed: 12/02/2022]
Abstract
INTRODUCTION Early and safe ambulation can facilitate same-day discharge (SDD) following catheter ablation, which can reduce resource utilization and healthcare costs and improve patient satisfaction. This study evaluated procedure success and safety of the VASCADE MVP venous vascular closure system in patients with atrial fibrillation (AF). METHODS The AMBULATE SDD Registry is a two-stage series of postmarket studies in patients with paroxysmal or persistent AF undergoing catheter ablation followed by femoral venous access-site closure with VASCADE MVP. Efficacy endpoints included SDD success, defined as the proportion of patients discharged the same day who did not require next-day hospital intervention for procedure/access site-related complications, and access site sustained success within 15 days of the procedure. RESULTS Overall, 354 patients were included in the pooled study population, 151 (42.7%) treated for paroxysmal AF and 203 (57.3%) for persistent AF. SDD was achieved in 323 patients (91.2%) and, of these, 320 (99.1%) did not require subsequent hospital intervention based on all study performance outcomes. Nearly all patients (350 of 354; 98.9%) achieved total study success, with no subsequent hospital intervention required. No major access-site complications were recorded. Patients who had SDD were more likely to report procedure satisfaction than patients who stayed overnight. CONCLUSION In this study, 99.7% of patients achieving SDD required no additional hospital intervention for access site-related complications during follow-up. SDD appears feasible and safe for eligible patients after catheter ablation for paroxysmal or persistent AF in which the VASCADE MVP is used for venous access-site closure.
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Affiliation(s)
- Zayd A Eldadah
- Heart & Vascular Institute, MedStar Health, Columbia, Maryland, USA
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - T Jared Bunch
- Department of Medicine, School of Medicine, University of Utah, Murray, Utah, USA
| | - David B Delurgio
- Department of Medicine, Emory University Hospital, Atlanta, Georgia, USA
| | - Rahul N Doshi
- Cardiac Arrhythmia Group, HonorHealth Medical Group, Scottsdale, Arizona, USA
| | - Bruce G Hook
- Department of Cardiology, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA
| | | | - Charles A Joyner
- Department of Cardiology, Levinson Heart Hospital at Chippenham and Johnston Willis Medical Center, Richmond, Virginia, USA
| | - Suneet Mittal
- Electrophysiology, Valley Health System, Ridgewood, New Jersey, USA
| | | | - Javier E Sanchez
- Texas Cardiac Arrhythmia, Medical City Dallas, Dallas, Texas, USA
| | | | - Oussama M Wazni
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - H Thomas McElderry
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Kogelschatz B, Zenger B, Steinberg BA, Ranjan R, Jared Bunch T. Atrial fibrillation and the risk of early-onset dementia and cognitive decline: An updated review. Trends Cardiovasc Med 2023:S1050-1738(23)00007-5. [PMID: 36702389 DOI: 10.1016/j.tcm.2023.01.005] [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: 12/02/2022] [Revised: 01/02/2023] [Accepted: 01/18/2023] [Indexed: 01/25/2023]
Abstract
The relationship between atrial fibrillation (AF) and dementia has been well described; however, recent data suggest that AF confers a greater risk for the development of early-onset dementia irrespective of clinical stroke. Numerous mechanisms have been hypothesized to explain cognitive decline in the setting of AF, including silent cerebral ischemia, cerebral hypoperfusion, and cerebral microvascular disease. Despite the emergence of data supporting the increased risk of early-onset dementia in patients with AF, the underlying mechanism remains unclear. Furthermore, the mechanism may be influenced by survival bias, genetic susceptibility, or early dysfunction of brain adaptation. Investigation into why this relationship exists could change how prevention and treatment are evaluated.
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Affiliation(s)
- Benjamin Kogelschatz
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132 USA
| | - Brian Zenger
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132 USA
| | - Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132 USA
| | - Ravi Ranjan
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132 USA
| | - T Jared 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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Bunch TJ. State of the Journal 2023: Heart Rhythm Case Reports. HeartRhythm Case Rep 2023; 9:1. [PMID: 36685691 PMCID: PMC9845642 DOI: 10.1016/j.hrcr.2022.11.005] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- T. Jared Bunch
- Address reprint requests and correspondence: Dr T. Jared Bunch, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132.
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Kamali R, Kwan E, Regouski M, Bunch TJ, Dosdall DJ, Hsu E, Macleod RS, Polejaeva I, Ranjan R. Contribution of atrial myofiber architecture to atrial fibrillation. PLoS One 2023; 18:e0279974. [PMID: 36719871 PMCID: PMC9888724 DOI: 10.1371/journal.pone.0279974] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 12/19/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The role of fiber orientation on a global chamber level in sustaining atrial fibrillation (AF) is unknown. The goal of this study was to correlate the fiber direction derived from Diffusion Tensor Imaging (DTI) with AF inducibility. METHODS Transgenic goats with cardiac-specific overexpression of constitutively active TGF-β1 (n = 14) underwent AF inducibility testing by rapid pacing in the left atrium. We chose a minimum of 10 minutes of sustained AF as a cut-off for AF inducibility. Explanted hearts underwent DTI to determine the fiber direction. Using tractography data, we clustered, visualized, and quantified the fiber helix angles in 8 different regions of the left atrial wall using two reference vectors defined based on anatomical landmarks. RESULTS Sustained AF was induced in 7 out of 14 goats. The mean helix fiber angles in 7 out of 8 selected regions were statistically different (P-Value < 0.05) in the AF inducible group. The average fractional anisotropy (FA) and the mean diffusivity (MD) were similar in the two groups with FA of 0.32±0.08 and MD of 8.54±1.72 mm2/s in the non-inducible group and FA of 0.31±0.05 (P-value = 0.90) and MD of 8.68±1.60 mm2/s (P-value = 0.88) in the inducible group. CONCLUSIONS DTI based fiber direction shows significant variability across subjects with a significant difference between animals that are AF inducible versus animals that are not inducible. Fiber direction might be contributing to the initiation and sustaining of AF, and its role needs to be investigated further.
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Affiliation(s)
- Roya Kamali
- Department of Bioengineering, University of Utah, Salt Lake City, Utah, United States of America
- Cardiovascular Medicine, University of Utah, Salt Lake City, Utah, United States of America
- Nora Eccles Harrison Cardiovascular Research and Training Institute, Salt Lake City, Utah, United States of America
| | - Eugene Kwan
- Department of Bioengineering, University of Utah, Salt Lake City, Utah, United States of America
- Cardiovascular Medicine, University of Utah, Salt Lake City, Utah, United States of America
- Nora Eccles Harrison Cardiovascular Research and Training Institute, Salt Lake City, Utah, United States of America
| | - Misha Regouski
- Department of Animal, Dairy and Veterinary Sciences, Utah State University, Logan, Utah, United States of America
| | - T. Jared Bunch
- Cardiovascular Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Derek J. Dosdall
- Department of Bioengineering, University of Utah, Salt Lake City, Utah, United States of America
- Cardiovascular Medicine, University of Utah, Salt Lake City, Utah, United States of America
- Nora Eccles Harrison Cardiovascular Research and Training Institute, Salt Lake City, Utah, United States of America
- Department of Surgery, University of Utah, Salt Lake City, Utah, United States of America
| | - Ed Hsu
- Department of Bioengineering, University of Utah, Salt Lake City, Utah, United States of America
| | - Rob S. Macleod
- Department of Bioengineering, University of Utah, Salt Lake City, Utah, United States of America
| | - Irina Polejaeva
- Department of Animal, Dairy and Veterinary Sciences, Utah State University, Logan, Utah, United States of America
| | - Ravi Ranjan
- Department of Bioengineering, University of Utah, Salt Lake City, Utah, United States of America
- Cardiovascular Medicine, University of Utah, Salt Lake City, Utah, United States of America
- Nora Eccles Harrison Cardiovascular Research and Training Institute, Salt Lake City, Utah, United States of America
- * E-mail:
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Zenger B, Rizzi S, Steinberg BA, Ranjan R, Bunch TJ. This is Your Brain, and This is Your Brain on Atrial Fibrillation: The Roles of Cardiac Malperfusion Events and Vascular Dysfunction in Cognitive Impairment. Arrhythm Electrophysiol Rev 2023; 12:e01. [PMID: 36845168 PMCID: PMC9945461 DOI: 10.15420/aer.2022.29] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/14/2022] [Indexed: 02/03/2023] Open
Abstract
AF is an independent and strong predictor of long-term cognitive decline. However, the mechanism for this cognitive decline is difficult to define and likely multifactorial, leading to many different hypotheses. Examples include macro- or microvascular stroke events, biochemical changes to the blood-brain barrier related to anticoagulation, or hypo-hyperperfusion events. This review explores and discusses the hypothesis that AF contributes to cognitive decline and dementia through hypo-hyperperfusion events occurring during cardiac arrhythmias. We briefly explain several brain perfusion imaging techniques and further examine the novel findings associated with changes in brain perfusion in patients with AF. Finally, we discuss the implications and areas requiring more research to further understand and treat patients with cognitive decline related to AF.
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Affiliation(s)
- Brian Zenger
- School of Medicine, University of Utah, Salt Lake City, UT, US
| | - Scott Rizzi
- Department of Internal Medicine, University of Utah Health Sciences, Salt Lake City, UT, US
| | - Benjamin A Steinberg
- School of Medicine, University of Utah, Salt Lake City, UT, US
- Division of Cardiovascular Medicine, University of Utah Health Sciences, Salt Lake City, UT, US
| | - Ravi Ranjan
- Division of Cardiovascular Medicine, University of Utah Health Sciences, Salt Lake City, UT, US
| | - T Jared Bunch
- School of Medicine, University of Utah, Salt Lake City, UT, US
- Division of Cardiovascular Medicine, University of Utah Health Sciences, Salt Lake City, UT, US
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27
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Zeitler EP, Bunch TJ, Khanna R, Fan X, Iglesias M, Russo AM. Comparative risk of dementia among patients with atrial fibrillation treated with catheter ablation versus anti-arrhythmic drugs. Am Heart J 2022; 254:194-202. [PMID: 36245141 DOI: 10.1016/j.ahj.2022.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 07/15/2022] [Revised: 09/11/2022] [Accepted: 09/15/2022] [Indexed: 06/16/2023]
Abstract
Atrial fibrillation (AF) is associated with an increased risk of dementia. Emerging evidence suggests AF suppression is associated with reduced risk of dementia, but the optimal strategy to achieve this is unknown. We sought to compare the risk of dementia in patients with AF who underwent catheter ablation (CA) versus anti-arrhythmic drug (AAD) treatment. METHODS AND RESULTS: Using the 2000 to 2021 Optum Clinformatics database, patients with AF who underwent CA versus AAD treatment (≥1 prescription fill for ≥2 different AADs) were identified and propensity score matched overall and within sex subgroups. A cause-specific hazard model was performed to assess dementia overall and in sex-specific subgroups. After matching, there were 19,088 patients per group. CA was associated with a 41% lower risk of dementia compared with AAD alone (1.9% vs 3.3%; hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.52-0.67, log-rank P < .0001). When examined by sex, dementia risk reduction associated with CA versus AAD use alone was observed among both males (HR 0.55, 95% CI 0.46-0.66) and females (HR 0.60, 95% CI 0.50-0.72). Though not studied as a primary outcome, patients treated with CA were also observed to have 49% lower associated risk of mortality compared with AAD only (HR 0.51 95% CI 0.46-0.55, P < .0001). CONCLUSIONS: Among patients treated for AF, CA was associated with significantly lower risk of dementia and death compared with AADs only. These reductions in risk associated with CA versus AAD were seen in both males and females.
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Affiliation(s)
| | - T Jared Bunch
- University of Utah School of Medicine, Salt Lake City, UT
| | - Rahul Khanna
- Medical Device Epidemiology and Real-World Data Sciences, Johnson and Johnson, New Brunswick, NJ
| | - Xiaozhou Fan
- Medical Device Epidemiology and Real-World Data Sciences, Johnson and Johnson, New Brunswick, NJ
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Prasitlumkum N, Navaravong L, Desai A, Desai D, Cheungpasitporn W, Rattanawong P, Bunch TJ, Jongnarangsin K, Chokesuwattanaskul R. Impact of early ventricular tachycardia ablation in patients with an implantable cardioverter-defibrillator: An updated systematic review and meta-analysis of randomized controlled trials. Heart Rhythm 2022; 19:2054-2061. [PMID: 35820619 DOI: 10.1016/j.hrthm.2022.07.005] [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: 05/17/2022] [Revised: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is limited information on whether early catheter ablation (CA) for ventricular tachycardia (VT) is associated with better outcomes compared with alternative strategies in patients with implantable cardioverter-defibrillator (ICD). OBJECTIVE The purpose of this article was to assess the efficacy of early VT CA in patients with ICD. METHODS EMBASE, PubMed, and Cochrane were searched from inception to April 2022. Randomized controlled trials comparing the efficacy of early VT CA with control groups, both in patients with ICD, were included in the analysis. Data on effect estimates in individual studies were extracted and combined via random effects meta-analysis using the DerSimonian and Laird method, a generic inverse variance strategy. RESULTS Nine randomized controlled trials with 1106 patients (n = 1018, 92.1% with ischemic cardiomyopathy and n = 88, 7.9% with nonischemic cardiomyopathy) were evaluated. VT CA was associated with reduced VT recurrences (odds ratio [OR] 0.64; P = .007), appropriate ICD shocks (OR 0.53; P = .002), ICD therapies (OR 0.54; P = .002), and cardiovascular hospitalization (OR 0.67; P = .004). However, no significant differences were observed in terms of mortality rate, heart failure hospitalization, and quality of life between the early VT CA and control groups. CONCLUSION Early CA was beneficial in reducing VT burden and ICD therapies. However, it did not affect mortality rate and quality of life. Since most patients in the included studies presented with ischemic cardiomyopathy, further studies on nonischemic cardiomyopathy should be conducted to validate if early CA has similar outcomes.
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Affiliation(s)
- Narut Prasitlumkum
- Department of Cardiology, University of California Riverside, Riverside, California
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Aditya Desai
- Department of Internal Medicine, University of California Riverside, Riverside, California
| | - Darshi Desai
- Department of Internal Medicine, University of California Riverside, Riverside, California
| | | | | | - T Jared Bunch
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Krit Jongnarangsin
- Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan Health, Ann Arbor, Michigan
| | - Ronpichai Chokesuwattanaskul
- Division of Cardiovascular Medicine, Department of Medicine, Cardiac Center, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
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29
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Rizzi SA, Torre M, Bunch TJ, Fang J, Hess R, Rodriguez-Correa C, Spertus JA, Stehlik J, Zhang M, Zhang Y, Steinberg BA. Ejection Fraction Improvement Does Not Reflect Changes in Quality of Life Following Cardiac Resynchronization Therapy. Crit Pathw Cardiol 2022; 21:201-205. [PMID: 36413400 PMCID: PMC9720911 DOI: 10.1097/hpc.0000000000000299] [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] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine if health-related quality of life (HRQoL) improvement after cardiac resynchronization therapy (CRT) correlates with improved left-ventricular ejection fraction (EF). BACKGROUND CRT was reported to improve EF and HRQoL in clinical trials of heart failure with reduced EF (HFrEF). It is unknown if improvements in HRQoL reflect EF response to CRT. METHODS We included HFrEF patients who underwent CRT and had both pre- and post-CRT HRQoL assessment. EF response was categorized as absent (0% change or decrease), modest (0%-19% increase), or significant ( > 20% increase). We examined the associations between EF response and generic (PROMIS) and HF-specific (KCCQ-12) HRQoL. RESULTS The group included 115 patients with mean age of 65 years and baseline EF of 31%; 39% were female (n = 45). Nineteen percent (n = 22) had significant, 57% (n = 66) modest, and 23% (n = 27) absent EF responses. AF burden across significant (8.9%), modest (4.8%), and absent EF responders (1.4%) was similar ( P = 0.20). Significant improvements in KCCQ-12 (43.4-57.5, P = 0.003), current health visual analog scale (49.1-55.9, P = 0.042), PROMIS fatigue (58.9-55.1, P = 0.026), and PROMIS satisfaction (42.7-46.4, P = 0.020) resulted following CRT across all groups. There was no association between significant EF improvement and HRQoL by KCCQ-12 (nonresponse, 44.4%; modest response, 33.3%; and significant response, 22.2%) at 1 year ( P = 0.52 across all groups). CONCLUSION CRT was associated with a modest to significant EF response in a majority of patients. However, EF response did not significantly correlate with generic or HF-specific HRQoL measures. Further investigations are warranted into determinants of improved HRQoL following CRT.
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Affiliation(s)
- Scott A. Rizzi
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Michael Torre
- Department of Population Health, University of Utah School of Medicine, Salt Lake City, UT
| | - T. Jared Bunch
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - James Fang
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Rachel Hess
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
- University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | | | - John A. Spertus
- University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Josef Stehlik
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Mingyuan Zhang
- Department of Population Health, University of Utah School of Medicine, Salt Lake City, UT
| | - Yue Zhang
- Department of Population Health, University of Utah School of Medicine, Salt Lake City, UT
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Bunch TJ. EP News: Case Reports. Heart Rhythm 2022; 19:1922. [PMID: 37850597 DOI: 10.1016/j.hrthm.2022.08.038] [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] [Received: 08/31/2022] [Accepted: 08/31/2022] [Indexed: 11/26/2022]
Affiliation(s)
- T Jared Bunch
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah.
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32
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Zenger B, Kwan E, Kholmovski E, Peckham ME, Steinberg BA, deHavenon A, Ranjan R, Bunch TJ. Atrial Fibrillation Causes Decreased Cerebrovascular Reserve: A Controlled Experimental Study. JACC Clin Electrophysiol 2022; 8:1451-1453. [PMID: 36089520 DOI: 10.1016/j.jacep.2022.06.008] [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: 04/28/2022] [Revised: 06/14/2022] [Accepted: 06/19/2022] [Indexed: 12/24/2022]
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Lange M, Kwan E, Dosdall DJ, MacLeod RS, Bunch TJ, Ranjan R. Case report: Personalized computational model guided ablation for left atrial flutter. Front Cardiovasc Med 2022; 9:893752. [PMID: 36187013 PMCID: PMC9521648 DOI: 10.3389/fcvm.2022.893752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/04/2022] [Indexed: 11/21/2022] Open
Abstract
Atypical atrial flutter is seen post-ablation in patients, and it can be challenging to map. These flutters are typically set up around areas of scar in the left atrium. MRI can reliably identify left atrial scar. We propose a personalized computational model using patient specific scar information, to generate a monodomain model. In the model conductivities are adjusted for different tissue regions and flutter was induced with a premature pacing protocol. The model was tested prospectively in patients undergoing atypical flutter ablation. The simulation-predicted flutters were visualized and presented to clinicians. Validation of the computational model was motivated by recording from electroanatomical mapping. These personalized models successfully predicted clinically observed atypical flutter circuits and at times even better than invasive maps leading to flutter termination at isthmus sites predicted by the model.
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Affiliation(s)
- Matthias Lange
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, UT, United States
| | - Eugene Kwan
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, UT, United States
- Biomedical Engineering, The University of Utah, Salt Lake City, UT, United States
| | - Derek J. Dosdall
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, UT, United States
- Biomedical Engineering, The University of Utah, Salt Lake City, UT, United States
- Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Rob S. MacLeod
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, UT, United States
- Biomedical Engineering, The University of Utah, Salt Lake City, UT, United States
- Scientific Computing and Imaging Institute, The University of Utah, Salt Lake City, UT, United States
| | - T. Jared Bunch
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Ravi Ranjan
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, UT, United States
- Biomedical Engineering, The University of Utah, Salt Lake City, UT, United States
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
- *Correspondence: Ravi Ranjan,
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36
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Handelsman Y, Bunch TJ, Rodbard HW, Steinberg BA, Thind M, Bigot G, Konigsberg L, Wieloch M, Kowey PR. Impact of dronedarone on patients with atrial fibrillation and diabetes: A sub-analysis of the ATHENA and EURIDIS/ADONIS studies. J Diabetes Complications 2022; 36:108227. [PMID: 35717354 DOI: 10.1016/j.jdiacomp.2022.108227] [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: 03/24/2022] [Revised: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 11/27/2022]
Abstract
AIM This post hoc analysis evaluated efficacy and safety of dronedarone in atrial fibrillation (AF) and atrial flutter (AFL) patients with/without diabetes. METHODS Patients were categorized according to baseline diabetes status. Time-to-event analyses were performed using Kaplan-Meier method. Hazard-ratios were assessed using Cox models. RESULTS 945/4628 (dronedarone = 482; placebo = 463) patients in ATHENA and 215/1237 (dronedarone = 148; placebo = 67) patients in EURIDIS/ADONIS studies had diabetes. In ATHENA, there were higher rates of CV hospitalization/death in patients with diabetes (39.5%) than without diabetes (34.7%). Incidence of first CV hospitalization/death was lower in patients with diabetes treated with dronedarone (35.1%) than placebo (44.1%), and time to this event was longer in those treated with dronedarone than placebo (log-rank p = 0.005). Median AF/AFL recurrence time was longer in patients treated with dronedarone than placebo in patients with diabetes (ATHENA: 722 vs 527 days, log-rank p = 0.004; EURIDIS/ADONIS: 100 vs 23 days, log-rank p = 0.15) or without diabetes (ATHENA: 741 vs 492 days, log-rank p < 0.0001; EURIDIS/ADONIS: 120 vs 59 days, log-rank p = 0.0002). Occurrence of any treatment-related adverse events with dronedarone was similar for patients with/without diabetes and was comparable to placebo. CONCLUSIONS Dronedarone reduced incidence of CV hospitalization/death, AF/AFL recurrence and increased time to these events in AF/AFL patients with/without diabetes. TRIAL REGISTRATION Not applicable, as it was a post hoc analysis. This article is based on previously conducted studies (ATHENA: NCT00174785, EURIDIS: NCT00259428, and ADONIS: NCT00259376).
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Affiliation(s)
- Yehuda Handelsman
- Metabolic Institute of America, Tarzana, CA, United States of America.
| | - T Jared Bunch
- School of Medicine, University of Utah, Salt Lake City, UT, United States of America.
| | - Helena W Rodbard
- Endocrine and Metabolic Consultants, Rockville, MD, United States of America.
| | - Benjamin A Steinberg
- School of Medicine, University of Utah, Salt Lake City, UT, United States of America.
| | - Munveer Thind
- Lankenau Heart Institute, Lankenau Medical Center, Wynnewood, PA, United States of America.
| | | | | | - Mattias Wieloch
- Sanofi, Paris, France; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.
| | - Peter R Kowey
- Lankenau Heart Institute, Lankenau Medical Center, Wynnewood, PA, United States of America.
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Steinberg BA, Bunch TJ. Measuring 'Symptomatic' Atrial Fibrillation: One View is No View. Heart Rhythm 2022; 19:1412-1413. [PMID: 35768024 DOI: 10.1016/j.hrthm.2022.06.028] [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] [Received: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - T Jared Bunch
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT.
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Sandhu RK, Seiler A, Johnson CJ, Bunch TJ, Deering TF, Deneke T, Kirchhof P, Natale A, Piccini JP, Russo AM, Hills MT, Varosy PD, Araia A, Smith AM, Freeman J. Heart Rhythm Society Atrial Fibrillation Centers of Excellence Study: A survey analysis of stakeholder practices, needs, and barriers. Heart Rhythm 2022; 19:1039-1048. [PMID: 35428582 DOI: 10.1016/j.hrthm.2022.02.022] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/31/2022] [Accepted: 02/17/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND An integrated, coordinated, and patient-centered approach to atrial fibrillation (AF) care delivery may improve outcomes and reduce cost. OBJECTIVE The purpose of this study was to gain a better understanding from key stakeholder groups on current practices, needs, and potential barriers to implementing optimal integrated AF care. METHODS A series of comprehensive questionnaires were designed by the Heart Rhythm Society Atrial Fibrillation Centers of Excellence (CoE) Task Force to conduct surveys with physicians, advanced practice professionals, patients, and hospital administrators. Data collected focused on the following areas: access to care, stroke prevention, education, AF quality improvement, and AF CoE needs and barriers. Survey responses were collated and analyzed by the Task Force. RESULTS The surveys identified 5 major unmet needs: (1) Standardized protocols, order sets, or care pathways in the emergency department or inpatient setting were uncommon (36%-42%). (2) All stakeholders agreed stroke prevention was a top priority; however, prior bleeding or risk of bleeding was the most frequent barrier for initiation. (3) Patients indicated that education on modifiable causes, AF-related complications, and lowering stroke risk is most important. (4) Less than half (43%) of the health care systems track patients with AF or treatment status. Patients reported that stroke and heart failure prevention and access to procedures were priority areas for an AF CoE. The most common barriers to implementing AF CoE identified by clinicians were administrative support (69%) and cost (52%); administrators reported physical space (43%). CONCLUSION On the basis of the findings of this study, the Task Force identified high priority areas to develop initiatives to aid the implementation of AF CoE.
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Affiliation(s)
- Roopinder K Sandhu
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | | | - Colleen J Johnson
- Southeast Louisiana Veterans Healthcare System, Tulane University, New Orleans, Louisiana
| | - T Jared Bunch
- University of Utah School of Medicine, Salt Lake City, Utah
| | | | | | - Paulus Kirchhof
- University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | | | | | - Andrea M Russo
- Cooper Medical School at Rowan University, Camden, New Jersey
| | | | - Paul D Varosy
- VA Eastern Colorado Health Care Systems, Aurora, Colorado; University of Colorado, Aurora, Colorado
| | - Almaz Araia
- Heart Rhythm Society, Washington, District of Columbia
| | | | - James Freeman
- Yale University School of Medicine, New Haven, Connecticut
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Bunch TJ. Brain Health in Patients With Atrial Fibrillation-Another Reason to Quit Smoking Now. JAMA Netw Open 2022; 5:e2217141. [PMID: 35704323 DOI: 10.1001/jamanetworkopen.2022.17141] [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: 11/14/2022] Open
Affiliation(s)
- T Jared Bunch
- Division of Cardiovascular Medicine, Department of Medicine, School of Medicine, University of Utah, Salt Lake City
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Monahan KH, Bunch TJ, Mark DB, Poole JE, Bahnson TD, Al-Khalidi HR, Silverstein AP, Daniels MR, Lee KL, Packer DL. Influence of atrial fibrillation type on outcomes of ablation vs. drug therapy: results from CABANA. Europace 2022; 24:1430-1440. [PMID: 35640922 DOI: 10.1093/europace/euac055] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/10/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS Influence of atrial fibrillation (AF) type on outcomes seen with catheter ablation vs. drug therapy is incompletely understood. This study assesses the impact of AF type on treatment outcomes in the Catheter Ablation vs. Antiarrhythmic Drug Therapy for Atrial Fibrillation Trial (CABANA). METHODS AND RESULTS CABANA randomized 2204 patients ≥65 years old or <65 with at least one risk factor for stroke to catheter ablation or drug therapy. Of these, 946 (42.9%) had paroxysmal AF (PAF), 1042 (47.3%) had persistent AF (PersAF), and 215 (9.8%) had long-standing persistent AF (LSPAF) at baseline. The primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Symptoms were measured with the Mayo AF-Specific Symptom Inventory (MAFSI), and quality of life was measured with the Atrial Fibrillation Effect on Quality of Life (AFEQT). Comparisons are reported by intention to treat. Compared with drug therapy alone, catheter ablation produced a 19% relative risk reduction in the primary endpoint for PAF {adjusted hazard ratio [aHR]: 0.81 [95% confidence interval (CI): 0.50, 1.30]}, and a 17% relative reduction for PersAF (aHR: 0.83, 95% CI: 0.56, 1.22). For LSPAF, the ablation relative effect was a 7% reduction (aHR: 0.93, 95% CI: 0.36, 2.44). Ablation was more effective than drug therapy at reducing first AF recurrence in all AF types: by 51% for PAF (aHR: 0.49, 95% CI: 0.39, 0.62), by 47% for PersAF (aHR: 0.53, 95% CI: 0.43,0.65), and by 36% for LSPAF (aHR 0.64, 95% CI 0.41,1.00). Ablation was associated with greater improvement in symptoms, with the mean difference between groups in the MAFSI frequency score favouring ablation over 5 years of follow-up in all subgroups: PAF had a clinically significant -1.9-point difference (95% CI: -1.2 to -2.6); PersAF a -0.9 difference (95% CI: -0.2 to -1.6); LSPAF a clinically significant difference of -1.6 points (95% CI: -0.1 to -3.1). Ablation was also associated with greater improvement in quality of life in all subgroups, with the AFEQT overall score in PAF patients showing a clinically significant 5.3-point improvement (95% CI: 3.3 to 7.3) over drug therapy alone over 5 years of follow-up, PersAF a 1.7-point difference (95% CI: 0.0 to 3.7), and LSPAF a 3.1-point difference (95% CI: -1.6 to 7.8). CONCLUSION Prognostic treatment effects of catheter ablation compared with drug therapy on the primary and major secondary clinical endpoints did not differ consequentially by AF subtype. With regard to decreases in AF recurrence and improving quality of life, ablation was more effective than drug therapy in all three AF type subgroups. CLINICALTRIALS.GOV IDENTIFIER NCT00911508.
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Affiliation(s)
| | - T Jared Bunch
- Intermountain Health Care, University of Utah, Salt Lake City, UT 84132, USA
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
| | - Jeanne E Poole
- University of Washington Medical Center, University of Washington, Seattle, WA 98195, USA
| | - Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
| | | | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
| | - Melanie R Daniels
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
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Ishidoya Y, Kwan E, Dosdall DJ, Macleod RS, Navaravong L, Steinberg BA, Jared Bunch T, Ranjan R. Shorter Distance Between The Esophagus And The Left Atrium Is Associated With Higher Rates Of Esophageal Thermal Injury After Radiofrequency Ablation. J Cardiovasc Electrophysiol 2022; 33:1460-1471. [DOI: 10.1111/jce.15554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 04/29/2022] [Accepted: 05/11/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Yuki Ishidoya
- Division of Cardiovascular Medicine University of Utah Salt Lake City Utah
- Nora Eccles Harrison Cardiovascular Research and Training Institute University of Utah Salt Lake City Utah
| | - Eugene Kwan
- Division of Cardiovascular Medicine University of Utah Salt Lake City Utah
- Nora Eccles Harrison Cardiovascular Research and Training Institute University of Utah Salt Lake City Utah
- Biomedical Engineering University of Utah Salt Lake City Utah
| | - Derek J. Dosdall
- Division of Cardiovascular Medicine University of Utah Salt Lake City Utah
- Nora Eccles Harrison Cardiovascular Research and Training Institute University of Utah Salt Lake City Utah
- Biomedical Engineering University of Utah Salt Lake City Utah
- Division of Cardiothoracic Surgery, School of Medicine Department of Utah Salt Lake City Utah
| | - Rob S. Macleod
- Nora Eccles Harrison Cardiovascular Research and Training Institute University of Utah Salt Lake City Utah
- Biomedical Engineering University of Utah Salt Lake City Utah
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine University of Utah Salt Lake City Utah
- Nora Eccles Harrison Cardiovascular Research and Training Institute University of Utah Salt Lake City Utah
| | - Benjamin A. Steinberg
- Division of Cardiovascular Medicine University of Utah Salt Lake City Utah
- Nora Eccles Harrison Cardiovascular Research and Training Institute University of Utah Salt Lake City Utah
| | - T. Jared Bunch
- Division of Cardiovascular Medicine University of Utah Salt Lake City Utah
- Nora Eccles Harrison Cardiovascular Research and Training Institute University of Utah Salt Lake City Utah
| | - Ravi Ranjan
- Division of Cardiovascular Medicine University of Utah Salt Lake City Utah
- Nora Eccles Harrison Cardiovascular Research and Training Institute University of Utah Salt Lake City Utah
- Biomedical Engineering University of Utah Salt Lake City Utah
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Ishidoya Y, Kwan E, Dosdall DJ, Macleod RS, Navaravong L, Steinberg BA, Jared Bunch T, Ranjan R. Short-Term Natural Course of Esophageal Thermal Injury After Ablation for Atrial Fibrillation. J Cardiovasc Electrophysiol 2022; 33:1450-1459. [PMID: 35606341 DOI: 10.1111/jce.15553] [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: 11/12/2021] [Revised: 04/19/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To provide insight into the short-term natural history of esophageal thermal injury (ETI) after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) by esophagogastroduodenoscopy (EGD). METHODS We screened patients who underwent RFCA for AF and EGD based on esophageal late gadolinium enhancement (LGE) in post ablation MRI. Patients with ETI diagnosed with EGD were included. We defined severity of ETI according to Kansas City classification (KCC): type 1: erythema; type 2: ulcers (2a: superficial; 2b deep); type 3 perforation (3a: perforation; 3b: perforation with atrioesophageal fistula). Repeated EGD was performed within 1-14 days after the last EGD if recommended and possible until any certain healing signs (visible reduction in size without deepening of ETI or complete resolution) were observed. RESULTS ETI was observed in 62 of 378 patients who underwent EGD after RFCA. Out of these 62 patients with ETI, 21% (13) were type 1, 50% (31) were type 2a and 29% (18) were type 2b at the initial EGD. All esophageal lesions, but one type 2b lesion that developed into an atrioesophageal fistula (AEF), showed signs of healing in repeated EGD studies within 14 days after the procedure. The one type 2b lesion developing into an AEF showed an increase in size and ulcer deepening in repeat EGD 8 days after the procedure. CONCLUSION We found that all ETI which didn't progress to AEF presented healing signs within 14 days after the procedure and that worsening ETI might be an early signal for developing esophageal perforation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yuki Ishidoya
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah.,Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
| | - Eugene Kwan
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah.,Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah.,Biomedical Engineering, University of Utah, Salt Lake City, Utah
| | - Derek J Dosdall
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah.,Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah.,Biomedical Engineering, University of Utah, Salt Lake City, Utah.,Division of Cardiothoracic Surgery, School of Medicine, Department of Utah, Salt Lake City, Utah
| | - Rob S Macleod
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah.,Biomedical Engineering, University of Utah, Salt Lake City, Utah
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah.,Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
| | - Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah.,Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
| | - T Jared Bunch
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah.,Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
| | - Ravi Ranjan
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah.,Biomedical Engineering, University of Utah, Salt Lake City, Utah
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Steinberg BA, Woolley S, Li H, Crawford C, Groh C, Navaravong L, Ranjan R, Zenger B, Zhang Y, Jared Bunch T. Patient‐reported Outcomes and Costs Associated with Vascular Closure and Same‐Day Discharge following Atrial Fibrillation Ablation. J Cardiovasc Electrophysiol 2022; 33:1737-1744. [PMID: 35598310 PMCID: PMC9398969 DOI: 10.1111/jce.15555] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/01/2022] [Accepted: 04/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND We aimed to measure patient-reported outcomes (PROs) and costs associated with same-day discharge (SDD) for atrial fibrillation (AF) ablation and vascular closure device implantation in clinical practice. METHODS PROs were prospectively measured in 50 AF ablation patients, comparing complete vascular device closure (n = 25) versus manual compression hemostasis (n = 25). Health-system costs for SDD patients receiving vascular device closure were compared to matched controls with one-night stays who did not receive any closure device. RESULTS Prospectively enrolled patients receiving vascular device closure for AF ablation had a mean age of 65 years, 17% were female, with a mean CHA2 DS2 -VASc score of 3. The mean number of venous sheaths was higher among patients receiving vascular device closure (3.8 vs. 3.1, p < 0.001), and there was one case of rebleeding in a patient receiving a vascular closure device (no other complications). Same-day discharge rates (76% vs. 8.3%, p < 0.001), patient satisfaction with bedrest time (8.5 vs. 6, p = 0.004) and with pain (8 vs. 5.1, p = 0.009) were significantly better among patients receiving vascular closure. In matched analyses of health-system costs, patients with vascular closure had mean age 66, 32% were female, and the mean CHA2 DS2 -VASc score was 2 (p = NS vs. controls). SDD with vascular closure was associated with the significantly lower facility, pharmacy, and disposable costs, but higher implant costs. Overall costs for ablation were not significantly different (mean difference 1.10%, 95% confidence interval [CI] -3.03 to 5.42). CONCLUSIONS Vascular closure for AF ablation improves patient experience in routine care. The use of vascular closure and SDD after AF ablation reduces several components of healthcare system costs, without an overall increase.
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Affiliation(s)
- Benjamin A. Steinberg
- Division of Cardiovascular MedicineUniversity of Utah Health Sciences CenterSalt Lake CityUT
| | - Shannon Woolley
- Division of Cardiovascular MedicineUniversity of Utah Health Sciences CenterSalt Lake CityUT
| | - Haojia Li
- Division of EpidemiologyDepartment of Internal MedicineUniversity of UtahSalt Lake CityUT
| | | | - Christopher Groh
- Division of Cardiovascular MedicineUniversity of Utah Health Sciences CenterSalt Lake CityUT
| | - Leenhapong Navaravong
- Division of Cardiovascular MedicineUniversity of Utah Health Sciences CenterSalt Lake CityUT
| | - Ravi Ranjan
- Division of Cardiovascular MedicineUniversity of Utah Health Sciences CenterSalt Lake CityUT
| | - Brian Zenger
- Division of Cardiovascular MedicineUniversity of Utah Health Sciences CenterSalt Lake CityUT
| | - Yue Zhang
- Division of EpidemiologyDepartment of Internal MedicineUniversity of UtahSalt Lake CityUT
| | - T. Jared Bunch
- Division of Cardiovascular MedicineUniversity of Utah Health Sciences CenterSalt Lake CityUT
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Prasitlumkum N, Tokavanich N, Trongtorsak A, Cheungpasitporn W, Kewcharoen J, Chokesuwattanaskul R, Akoum N, Jared Bunch T, Navaravong L. Catheter Ablation for Atrial Fibrillation in the Elderly > 75 Years old: Systematic Review and Meta-Analysis. J Cardiovasc Electrophysiol 2022; 33:1435-1449. [PMID: 35589557 DOI: 10.1111/jce.15549] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 02/16/2022] [Revised: 04/30/2022] [Accepted: 05/11/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) ablation is increasingly performed worldwide. As comfort with AF ablation increases, the procedure is increasingly used in patients that are older and in those with more comorbidities. However, it is not well established whether AF ablation in the elderly, especially those >75 years old, has comparable safety and efficacy to younger populations. OBJECTIVE To compare the efficacy and safety profiles in patients older than 75years undergoing AF ablation with younger patients. METHODS Databases from EMBASE, Medline, PubMed and Cochrane, were searched from inception through September 2021. Studies that compared the success rates in AF catheter ablation and all complications rates between patients who were older vs under 75 years were included. Effect estimates from the individual studies were extracted and combined using random effect, generic inverse variance method of DerSimonian and Laird. RESULTS Twenty-seven observational studies were included in the analysis consisting of 363,542 patients who underwent AF ablation. Comparing patients older than 75 years old to younger patients, there was no difference in the success of ablation rates between elderly and younger patients (pooled OR 0.85: 95% CI:0.69 - 1.05, p=0.131). On the other hand, AF ablation in the elderly was associated with higher complication rates (pooled OR 1.43: 95% CI:1.21 - 1.68, p<0.001) CONCLUSION: As AF ablation is expanded to elderly populations, our study found that AF ablation success rates were similar in both elderly and younger patients. However, older patients experience higher rates of complications that should be considered when offering the procedure and as a means to improve outcomes with future innovations. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Narut Prasitlumkum
- Division of Cardiology, University of California Riverside, Riverside, CA, USA
| | - Nithi Tokavanich
- Department of Cardiovascular Medicine, Vajira Hospital, Bangkok, Thailand
| | - Angkawipa Trongtorsak
- Department of Internal Medicine, AMITA Health Saint Francis Hospital, Evanston, IL, USA
| | | | - Jakrin Kewcharoen
- Department of Cardiovascular Medicine, Loma Linda University, Loma Linda, CA
| | - Ronpichai Chokesuwattanaskul
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Nazem Akoum
- Department of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - T Jared Bunch
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Scott M, Baykaner T, Bunch TJ, Piccini JP, Russo AM, Tzou WS, Zeitler EP, Steinberg BA. PO-652-05 TRENDS IN ELECTROPHYSIOLOGY PROCEDURES AND OPERATOR CHARACTERISTICS FROM 2013 TO 2019. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.248] [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: 11/04/2022]
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Abdelfattah O, Elsayed M, sayed A, Prasad R, Barakat AF, Elgendy I, Andrade JG, Bunch TJ, Thosani AJ, Saliba WI, Nakagawa H, Wazni OM, Hussein AA. PO-711-07 NETWORK META-ANALYSIS OF OPTIMAL INITIAL ATRIAL FIBRILLATION THERAPIES: CRYOABLATION, RADIOFREQUENCY ABLATION, AND ANTI-ARRHYTHMIC DRUGS. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.1132] [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: 11/16/2022]
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Ishidoya Y, Kwan E, Dosdall DJ, Navaravong L, Groh CA, Steinberg BA, Bunch TJ, Ranjan R. CA-528-02 SHORT-TERM NATURAL COURSE OF ESOPHAGEAL THERMAL INJURY AFTER RADIOFREQUENCY CATHETER ABLATION FOR ATRIAL FIBRILLATION. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.100] [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: 11/27/2022]
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Scheinman M, Bunch TJ, Singh M. A tale of 2 torsades: How to approach a patient with torsades de pointes and distinguish between classical and pseudo–torsades de pointes. HeartRhythm Case Rep 2022; 8:305-308. [PMID: 35497484 PMCID: PMC9039100 DOI: 10.1016/j.hrcr.2022.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Melvin Scheinman
- Division of Cardiology, Section on Electrophysiology, University of California San Francisco, San Francisco, California
| | - T. Jared Bunch
- Division of Cardiology, Department of Internal Medicine, University of Utah, Utah
| | - Mohita Singh
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Address reprint requests and correspondence: Dr Mohita Singh, Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.
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