Impact of ABC pathway adherence in high-risk patients with atrial fibrillation: an analysis from the ESC-EHRA EORP-AF long-term general registry

Background

The impact of Atrial Fibrillation Better Care (ABC) pathway adherence among high-risk subgroups of patients with atrial fibrillation (AF), ie. those with chronic kidney disease (CKD), advanced age and/or prior thromboembolism remains unknown. We evaluated the impact of ABC pathway adherence on clinical outcomes in these high-risk AF patients.

Methods

The EORP-AF General Long-Term Registry is a prospective, observational registry from 250 centres across 27 European countries. High-risk patients were defined as those with either CKD (eGFR <60 mL/min/1.73 m2), older age (≥75 years) and/or prior thromboembolism. The primary outcome was a composite event of all-cause death, any thromboembolism and acute coronary syndrome, evaluated according to ABC pathway adherence.

Results

A total of 6646 patients with AF were included (median age was 70 [IQR 61–77] years; 40.2% females). There were 3304 (54.2%) `high risk' patients with either CKD (n=1750), older age (n=2236) or prior thromboembolism (n=728). Among these there were 924 (28.0%) managed as adherent to ABC.

At 2-year follow-up, a total of 966 (14.5%) patients reported the primary outcome. The incidence of the primary outcome was significantly lower in high-risk patients managed as adherent to ABC pathway (IRR 0.53 [95% CI, 0.43–0.64]). Consistent results were obtained in the individual subgroups [Table]. Using multivariable Cox proportional hazards analysis, ABC adherence in the high-risk cohort was independently associated with a lower risk of primary outcome (aHR 0.64 [95% CI, 0.51–0.80]), as well as in the CKD (aHR 0.51 [95% CI, 0.37–0.70]) and elderly subgroups (aHR 0.69 [95% CI, 0.53–0.90]). Overall, there was greater reduction in the risk of primary outcome as more ABC criteria were fulfilled, both in the overall high-risk patients, as well as in the individual subgroups [Figure].

Conclusion

In a large, contemporary European AF cohort there was a significant proportion of high-risk patients. Among these, a low prevalence of integrated care, as assessed by adherence to ABC pathway, was found. Nonetheless, a clinical management adherent to the ABC pathway was associated with a significant reduction in the risk of adverse outcomes, the benefits of which were more significant with increasing number of ABC criteria adherent.

Funding Acknowledgement

Type of funding sources: None.

Effect of dronedarone versus placebo on atrial fibrillation progression: a post-hoc analysis from ATHENA trial

Background

Atrial fibrillation (AF) may progress over time, leading to greater AF burden. Data suggest that patients receiving rhythm control drugs are less likely to progress to more severe forms of AF vs those receiving a rate control strategy only. ATHENA (NCT00174785) demonstrated that dronedarone significantly decreased cardiovascular (CV) hospitalization and death [1], but it is unclear whether dronedarone affects progression of AF and atrial flutter (AFL).

Purpose

This post hoc analysis of ATHENA assessed (1) the effect of dronedarone on estimated AF/AFL burden, and (2) AF progression to presumed permanent AF/AFL or AF regression to sinus rhythm (SR).

Methods

AF/AFL burden was estimated using a modified Rosendaal method [2] based on status of all ECG assessments at each visit. Cumulative incidence of presumed permanent AF/AFL (defined as ≥6 months of AF/AFL until end of study) or preserved SR (≥6 months of SR until end of study) were calculated using the complement of Kaplan-Meier estimates. Log-rank test was used to assess statistical significance.

Results

Demographic characteristics in 2231 patients on placebo and 2208 on dronedarone were well balanced between groups. Overall, 304 (13.8%) dronedarone-treated patients progressed to presumed permanent AF/AFL compared with 455 (20.4%) treated with placebo. Patients progressing to presumed permanent AF/AFL tended to have larger left atrial diameters and lower left ventricular ejection fractions irrespective of treatment group. The cumulative incidence of presumed permanent AF/AFL was significantly lower in dronedarone-treated patients over time (log-rank p<0.0001; Figure 1). Estimated AF/AFL burden was lower in dronedarone-treated patients over time (Figure 2). Overall, 1149 (52.0%) dronedarone-treated patients had preserved SR compared with 1021 (45.8%) placebo-treated patients, and cumulative incidence of preserved SR was significantly higher in the dronedarone arm compared with the placebo arm (log-rank p<0.0001). Treatment-emergent adverse events were consistent with the findings in the main ATHENA analysis.

Conclusions

Dronedarone use was associated with fewer patients progressing to presumed permanent AF/AFL, more patients with AF/AFL regressing to preserved SR, and a lower estimated AF/AFL burden, suggesting a protective benefit against AF disease progression.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Sanofi

Dronedarone versus sotalol in patients with atrial fibrillation: a systematic literature review and network meta-analysis

Background

There are limited comparative data on safety and efficacy within Vaughn Williams class III anti-arrhythmic drugs (AADs) for maintenance of sinus rhythm in adults with atrial fibrillation (AF).

Purpose

We sought to compare the safety and efficacy of dronedarone and sotalol, two commonly prescribed Vaughn Williams class III AADs with class II rate-controlling properties in patients with non-permanent AF.

Methods

A systematic literature review was conducted by searching MEDLINE®, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) up to June 15, 2021. Clinical trials and observational studies that evaluated safety and efficacy of dronedarone or sotalol in adults with AF were included. Where feasible, Bayesian random-effects network meta-analysis (NMA) was conducted to estimate comparative safety and efficacy. Where possible, sensitivity analyses were conducted by including only randomized controlled trials (RCTs).

Results

Of 3,581 records identified through database searches, 37 unique studies (23 RCTs, 13 observational studies, and 1 non-randomized trial) were included in the NMA. Dronedarone was associated with a statistically significantly lower risk of all-cause death versus sotalol in the all-studies NMA (hazard ratio [HR]: 0.38; 95% credible interval [CrI]: 0.19, 0.74; 22 studies); sensitivity analysis followed the same trend numerically (HR: 0.46; 95% CrI: 0.21, 1.02; 16 RCTs). Risk ratios of AF recurrence were not significantly different between dronedarone and sotalol in both all-studies and sensitivity analyses.

Conclusion

Dronedarone, compared with sotalol, was associated with significantly lowered risk of all-cause death in the analysis combining RCTs and observational studies, with no differences in AF recurrence observed between the two therapies. This meta-analysis provides a comprehensive assessment of safety and efficacy evidence useful in evaluating treatment options in AF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Sanofi

Digitalised ECG measure of p-wave duration predicts incident heart failure

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Uppsala University Hospital

Background and purpose

Early identification of patients at risk of congestive heart failure (HF) may potentially alter their poor prognosis. The aim was therefore to test whether the P-wave and PR-interval, simple non-invasive ECG measures reflecting systolic and diastolic atrial function, could predict incident HF.

Methods

The PIVUS (Prospective Investigation of the Vasculature in Seniors) study including all individuals aged 70 years (1016 individuals, 50% women) was used to identify predictors of HF. Subjects with prevalent HF, QRS duration ≥ 130 msec or atrial arrhythmias on baseline ECG were excluded. Cox proportional hazard analysis was used to relate P-wave duration (Pdur), amplitude (Pamp) and PR interval in lead V1, to incident HF. Adjustment was performed for gender, RR-interval, beta-blocking agents, systolic blood pressure, body mass index and smoking.

Results

A total of 107 of 836 (12,8%) subjects at risk, developed HF during 15 years follow-up. The multivariate analysis, showed a strong U-shaped correlation between Pdur and incident HF (p=0.0001), which was significant for a Pdur< 60 msec [HR 2.75 (95% CI 1.87-4.06) at Pdur 40 msec]. There was no significant relationship between incident HF and the PR-interval, or the Pamp. A Pdur<60 msec improved discrimination by 3.7% when added to the confounders described above (p=0.048).

Conclusions

A short P-duration, a simple and easy ECG measure, may potentially be a useful predictor of developing HF, enabling early detection and treatment of HF.

Antiarrhythmic medication for atrial fibrillation (AIM-AF) study: a physician survey of antiarrhythmic drug (AAD) treatment practices and guideline adherence in Europe

Background

The 2020 European Society of Cardiology (ESC) guidelines provide detailed recommendations for the management of patients with atrial fibrillation (AF). In symptomatic patients, AADs are advised for rhythm control.

Purpose

This study was designed to investigate AAD treatment practices and adherence to guidelines in four European countries.

Methods

An online survey (n=321) of cardiologists or cardiac electrophysiologists (CDs) and interventional electrophysiologists (EPs) was conducted in Germany (DE; n=83), Italy (IT; n=95), Sweden (SE; n=60) and the UK (n=83). Respondents were actively treating ≥10 patients with AF.

Results

(1) The majority of physicians considered guidelines to be the most important non-patient factor influencing their AF management practices (pooled: 65%; range: 55–72%), with 96%

(range: 89–100%) following ESC guidelines. Although amiodarone use was most frequent in heart failure with reduced left ventricular (LV) ejection fraction (pooled: 91%; range: 88–93%) where it is a recommended first-line option, non-adherent AAD selection was common. Amiodarone was frequently selected as a typical treatment choice for minimal/no structural heart disease (SHD) where it is not recommended for initial therapy; this was particularly common in the UK versus SE (Figure 1). Other deviations included use of class 1C drugs in those with coronary artery disease (CAD) (with the exception of SE; Figure 1) and other SHD, as well as use of sotalol in LV hypertrophy (pooled: 30%) and renal impairment (Figure 1). Furthermore, absence of inpatient initiation of sotalol was generally high, with the exception of SE (Figure 1).

(2) Sotalol and dronedarone use in CAD varied between country (pooled: 28% [range: 16–41%] and pooled: 19% [range: 10–54%], respectively).

(3) CDs and EPs used rhythm control as initial therapy in most patients with paroxysmal AF (PAF); however, other than SE, this was not the case for persistent AF (Figure 2).

(4) AADs were preferred over ablation as initial therapy for individuals with infrequent, mildly symptomatic PAF (pooled: 61%), with the exception of SE (48%). Ablation was favoured for most patients with frequent, symptomatic PAF; however, in SE, AADs were preferred for infrequent, highly symptomatic PAF (53%) and frequent, symptomatic PAF (53%).

(5) Rhythm control therapies were selected for asymptomatic or subclinical AF; AADs were used more often (average: 41% [range: 22–60%]; ablation was used less frequently (average: 11% [range: 2–18%]).

Conclusion

Despite assertion that guidelines are the primary determinant for rhythm control treatment decisions, non-adherence was notable in European practice. While deviation may be reasonable in select individual patients, in general, non-adherence could compromise patient safety. As such, establishing the drivers of non-adherent practices is key, and education directed at clinicians to improve optimal and safe use of AADs is warranted in Europe.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Sanofi

Digoxin vs. beta-blocker therapy in atrial fibrillation: analysis from the ESC-EHRA EORP Atrial Fibrillation General Long-Term (AFGen LT) Registry

Background

There is a long-standing and unresolved controversy over the effects of digoxin on mortality. Furthermore, there is scarce evidence comparing the use of digoxin to beta-blocker in the general population with atrial fibrillation (AF). In this study, we aimed to evaluate the effects of digoxin over beta-blocker therapy among patients with AF.

Methods

Patients from the EORP-AF General Long-Term Registry with AF who were treated with either digoxin or beta-blocker were included. All patients were over 18 years old and had documented evidence of AF within 12 months prior to enrolment. The outcomes of interest were all-cause mortality, cardiovascular (CV) mortality, non-CV mortality and number of patients with unplanned hospitalisation (total and AF-related). These were recorded until the last known follow-up available.

Results

Of 6377 patients, 549 (8.6%) and 5828 (91.4%) were treated with digoxin and beta-blockers, respectively. Patients in the digoxin group were older (73 vs. 71 years, p<0.001) with reduced renal function (eGFR 65.4 vs. 68.7 mL/min/1.73m2, p=0.002), and had (in general) greater burden of comorbidities in terms of chronic kidney disease, chronic obstructive pulmonary disease, heart failure, hypertension and peripheral artery disease. Nonetheless, the use of anticoagulation therapy was comparable between both groups (p=0.112).

Over 24 months follow-up, there were 550 (8.6%) all-cause mortality and 1304 (23.6%) patients with unplanned emergency hospitalisation. Digoxin use was associated with increased all-cause mortality (hazard ratio [HR] 1.90 [95% CI, 1.48–2.44]), both from CV and non-CV causes (CV: HR 2.21 [95% CI, 1.49–3.26]); non-CV: HR 1.70 [95% CI, 1.04–2.79]). There was no statistical difference in terms of unplanned emergency hospitalisation (HR 0.99 [95% CI, 0.80–1.21]) and AF-related hospitalisation (HR 0.78 [95% CI, 0.58–1.06]) between both groups.

Using multivariable cox regression analysis, digoxin compared to beta-blocker therapy was independently linked to increased all-cause mortality (HR 1.52 [95% CI, 1.11–2.09]) and CV mortality (HR 1.82 [95% CI, 1.11–2.97]), but was not related to non-CV mortality (HR 1.31 [95% CI, 0.71–2.41]), emergency hospitalisation (HR 0.91 [95% CI, 0.71–1.16]) or AF-related hospitalisation (HR 0.88 [95% CI, 0.62–1.24]), after adjustment for known risk factors.

Conclusion

We demonstrated that the use of digoxin was independently associated with excess all-cause mortality, driven by CV death, but was non-inferior to beta-blocker in terms of preventing unplanned emergency or AF-related hospitalisation, after accounting for important risk factors.

Funding Acknowledgement

Type of funding sources: None.

Clinical application of the novel 4S-AF scheme for the characterisation of patients with atrial fibrillation: a report from the ESC-EHRA EORP Atrial Fibrillation General Long-Term (AFGen LT) registry

Background

Current classification systems recommended by major international guidelines are based on a single domain of atrial fibrillation (AF): temporal pattern, symptom severity or underlying comorbidity. Lack of integration between these various elements limits our approach to patients with AF and acts as a barrier against the delivery of better holistic care. The 4S-AF classification scheme was recently introduced as a means for the characterisation of patients with AF. It comprises of 4 domains: stroke risk (St), symptoms (Sy), severity of AF burden (Sb) and substrate (Su). We sought to examine the implementation of the 4S-AF scheme in the EORP-AF General Long-Term Registry and effects of individual domains on outcomes in AF.

Methods

Patients with AF from 250 centres across 27 participating European countries were included. All patients were over 18 years old and had electrocardiographic confirmation of AF within 12 months prior to enrolment. Data on demographics and comorbidities were collected at baseline. Individual domains of the 4S-AF scheme were assessed using the CHA2DS2-VASc score (St), European Heart Rhythm Association classification (Sy), temporal classification of AF (Sb), and cardiovascular risk factors and the degree of left atrial enlargement (Su). Each of these domains were used during multivariable cox regression analysis.

Results

A total of 6321 patients were included in the present analysis, corresponding to 57.0% of the original cohort of 11096 patients. The median age of patients was 70 (interquartile range [IQR] 62–77) years with 2615 (41.4%) females. Among these patients, 528 (8.4%) had low stroke risk (St=0), 3002 (47.5%) no or mild symptoms (Sy=0), 2558 (40.5%) newly diagnosed or paroxysmal AF (Sb=0), and 322 (5.1%) no cardiovascular risk factors or left atrial enlargement (Su=0).

Median follow-up was 24 months. Using multivariable cox regression analysis, independent predictors of all-cause mortality were (St) (adjusted hazard ratio [aHR] 8.21 [95% CI, 2.60–25.9]), (Sb) (aHR 1.21 [95% CI, 1.08–1.35]) and (Su) (aHR 1.27 [95% CI, 1.14–1.41]). For cardiovascular mortality and any thromboembolic event, only (Su) (aHR 1.73 [95% CI, 1.45–2.06]) and (Sy) (aHR 1.29 [95% CI, 1.00–1.66]) were statistically important, respectively. None of the domains were independently linked to ischaemic stroke or major bleeding.

Conclusion

Overall, we demonstrated that the 4S-AF scheme may be used to provide clinical characterisation of patients with AF using routinely collected data, and each of the domains within the 4S-AF scheme were independently associated with adverse long-term outcomes of all-cause mortality, cardiovascular mortality and/or any thromboembolic event.

Funding Acknowledgement

Type of funding sources: None.

Antiarrhythmic Medication for Atrial Fibrillation (AIM-AF) study: A physician survey of antiarrhythmic drug (AAD) treatment practices and guideline adherence in the EU and USA

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Sanofi

Introduction

The 2020 European Society of Cardiology and the 2019 USA (AHA/ACC/HRS) guidelines recommend the use of AADs for rhythm control in patients with symptomatic AF. This study sought to understand AAD treatment practices and adherence to guidelines across the EU and the USA.

Method

An online physician survey of cardiologists, cardiac electrophysiologists and interventional electrophysiologists (N = 569) was conducted in the USA, Germany, Italy and the UK. All respondents were actively treating ≥10 AF patients who received drug therapy and/or who had received or were referred for ablation. This extensively detailed survey explored questions on physician demographics, AF types, and drug treatment and ablation practices.

Results: Of the responses obtained

(1) Amiodarone was used frequently across co-morbidity categories (highest use in those with heart failure with reduced left ventricular ejection fraction [LVEF] [80%]), including in those in which it is not indicated for initial therapy (minimal or no structural heart disease: 26%). Other deviations from guideline recommendations, include: class 1C drugs were used with structural heart disease, including coronary artery disease (CAD) (average class 1C use in CAD-related comorbidities: 6%); sotalol was used with renal dysfunction (22%); and drugs such as sotalol and dofetilide were initiated out of hospital (56% and 17% of respondents, respectively). (2) Nonetheless, a majority of respondents (53%) considered guidelines as the most important non-patient factor in influencing their choice of AF management. (3) Rhythm control was selected more frequently as primary therapy for paroxysmal AF (PAF) (59% of patients) while rate control was used more often for persistent AF (53%). (4) For PAF, AADs were preferred as 1st line more often than ablation, especially if PAF was infrequent and mildly symptomatic (59% of respondents) while ablation was preferred more if frequent symptomatic PAF and for recurrent persistent AF. (5) Rhythm control (AAD or ablation) was chosen in notable numbers for asymptomatic AF and subclinical AF (AADs: 36% and 37%, respectively; ablation: 9% and 14%, respectively). (6) AAD use for those with a first or recurrent episodes of symptomatic AF was 60% or 47%, respectively. (7) Efficacy and safety were chosen as the most important considerations for choice of specific rhythm control therapy (49% and 33%, respectively), and reduction of mortality and cardiovascular hospitalisation (23%) were as important as maintaining sinus rhythm (26%) for rhythm therapy goals.

Conclusions

Although surveyed clinicians consider guidelines important, deviations in patient types and treatments chosen that compromise safety or were not indicated were common. Findings suggest a lack of understanding of the pharmacology and safe use of AADs, highlighting an important need for further education. Abstract Figure.

Impact of procedural volume on complication and recurrence rate after atrial fibrillation ablation in European centers. An ESC EORP Registry: Atrial Fibrillation Long-Term

Background

Catheter ablation has emerged as an effective therapy in patients with atrial fibrillation (AF). Despite high success rates of the method, there is still heterogeneity of outcomes and complications across Europe. A center's volume of AF ablations performed per year might also play an important role in the success rate of the procedure as compared to other confounding factors which may be different among centers (such as type of AF ablated, patient selection criteria, referral bias and/or ablation strategy).

Purpose

Aim of the study was to investigate differences in clinical outcomes and complication rates among European AF ablation centers related to the volume of ablations performed annually.

Methods

Data for this analysis were extracted from the European AF Ablation Long-Term Study, a prospective registry designed to describe the clinical epidemiology of patients undergoing AF ablation. Based on 33th and 67th percentiles of number of AF ablations performed, the participating centers were classified into high volume (HV) (≥180 procedures/year), medium volume (MV) (<180 and ≥74/year) and low volume (LV) (<74/year). One-year success was defined as patient survival free from any atrial arrhythmia, from the end of the 3-month blanking period to 12 months following the ablation procedure.

Results

A total of 91 centers in 26 European countries enrolled 3368 patients. There was a significantly higher reporting of cardiovascular complications in LV centers (5.2%), especially pericarditis and cardiac perforation, while the HV and MV centers reported cardiovascular complications in 3.0 and 4.3% of cases, respectively (p=0.039). Additionally, stroke incidence after ablation was significantly higher in LV centers (0.5% of cases vs 0% in HV and MV centers, p=0.008). One-year success after AF ablation ranged from 77.8% in HV vs 70.5% in LV vs 77.3% in MV centers (p<0.001). Despite these unadjusted differences, Kaplan-Meier survival analysis based on adjusted data demonstrated, however, that there were not significant differences in complication and recurrence rates according to volume's center (p=0.328 and p=0.476 accordingly, Figure A). This result was mainly driven by a proportional increase in severity/risk of cases ablated (as evidenced by CHA2DS2-VASc score and AF type) in relation to a center's procedural volume (Figure B).

Conclusions

Low volume centers present slightly higher cardiovascular complications' and stroke incidence and a lower unadjusted success rate after AF ablation. On the other hand, adjusted overall complication and recurrence rates are non-significantly different among different volume centers, a fact reflecting inhomogeneity of patient and procedural profiles and a counterbalance between expertise and risk level among participating centers.

Funding Acknowledgement

Type of funding source: None

P4762What do atrial fibrillation ablation procedural volume differences across European centers reflect? An ESC EORP registry: atrial fibrillation long-term

Background

Data from the European Atrial Fibrillation (AF) Ablation Long-Term Registry suggest that there are significant differences in the volume of AF ablation procedures performed across different centers even in the same country. If these differences in AF ablation volume between centers reflect regional, socioeconomic, infrastructural/technical or other disparities has not been addressed till now.

Purpose

The aim of this study was to investigate patient and non-patient related differences among European AF ablation centers according to the volume of AF ablations performed.

Methods

Data for this analysis originate from the European AF Ablation Long-Term Study, a prospective registry designed to describe the clinical epidemiology of patients undergoing AF ablation. Based on 25th and 75th percentiles of AF ablation numbers performed, the participating centers were classified into high volume (HV) (≥250 procedures/year), medium volume (MV) (<250 and ≥58/year) and low volume (LV) (<58/year). Patient (demographics, comorbidities) and non-patient (center infrastructure, procedural characteristics) related differences were assessed.

Results

A total of 91 centers in 26 European countries enrolled 3368 patients. There were no significant differences concerning regional distribution, hospital/cardiology facilities or services provided among centers with the exception of electrophysiology procedures and labs which were more abundant in HV centers (p=0.02 and <0.001 respectively). HV and MV centers ablate twice more cases of long-standing persistent and persistent AF compared to LV centers, in which paroxysmal AF reaches 78.9% of all cases (Figure A). Accordingly, first AF ablation procedure was far more frequent in LV centers compared to MV and HV (85.8% vs 76.0% vs 76.1% respectively, p<0.001). Even though HV centers ablate significantly more high risk patients (CHA2DS2-VASc score ≥2 51.4% in HV vs 46.5% in MV vs 37.2% in LV, p<0.001) (Figure B) with accompanying comorbidities, applying more elaborate ablation techniques, fluoroscopy time and radiation dose were higher among patients undergoing AF ablation in LV centers (p<0.001 for all). Despite the above-mentioned dissimilarities, Kaplan-Meier survival analysis, based on adjusted data, demonstrated non-significant differences in complication rate (p=0.402) or AF recurrence rate (p=0.363) among HV, MV and LV centers.

Conclusions

Volume of AF ablations in a center is not correlated with regional or infrastructural characteristics. The higher volume in HV centers consists mainly by more long-term persistent AF and higher risk patients, suggesting that differences in volume reflect differences in experience and personnel's commitment towards AF ablation.

5971Clinical impact of antithrombotic therapy in transvenous lead extraction complications: a sub-analysis from the ESC-EHRA ELECTRa (European Lead Extraction ConTRolled) Registry

Introduction

The complexity of candidates for transvenous lead extraction (TLE) has shown a parallel increase, both in terms of comorbidities, and of concomitant therapy, including antithrombotic therapy (AT). The management of candidates for TLE receiving concomitant AT is a debated issue, and only marginally the object of evidence-based recommendations in current guidelines. The ESC-EHRA European Lead Extraction ConTRolled Registry (ELECTRa) is a prospective registry of consecutive TLE procedures conducted by the European Heart Rhythm Association (EHRA) in order to identify the safety and efficacy of the current practice of TLE.

Purpose

The present study is a sub-analysis of the ESC-EHRA ELECTRa Registry conducted with the aim of evaluating the clinical impact of AT on TLE safety and efficacy.

Methods

All consecutive TLE patients enrolled in the ELECTRa registry were included. Success rate and procedural-related complications, including death, were compared between patients without AT therapy (No AT Group) and with different pre-operative AT regimens (AT subgroups), including antiplatelets (AP), anticoagulants (AC) or both (AP + AC).

Results

Out of 3510 TLE pts, 2398 (68%) were under AT pre-operatively. AT patients were older with more co-morbidities (p<0.0001). AT subgroups, defined as AP, AC or AP+AC, were 1096 (31.2%), 985 (28%) and 317 (9%), respectively. Regarding AP patients, 1413 (40%) were under AP, 1292 (91%) with a single AP and 121 (9%) with a dual AP therapy. AP was interrupted in 26% of pts 3.8±3.7 days before TLE. Regarding AC patients, 1302 (37%) patients were under AC,881 were under VKA (68%), 221 (17%) under DOAC, 155 (12%) under LWMH and 45 (3.5%) under UFH.AC pre-procedural management strategy included “interruption without bridging” in 696 (54%), “interruption with bridging” in 504 (39%) and a “continued” strategy in 87 (7%). AC was interrupted about 3.3±2.3 days before TLE.

TLE clinical success rate was high (98%) in all subgroups. Only the incidence of overall death (1.4%), but not the procedure-related, was higher in the AT subgroups (p=0.0500). (Figure A) Age >65 years and NYHA Class III/IV, but not AT regimens, were independent predictors of death for any cause.

Regarding minor complications, hematomas were more frequently observed between AC “continued” patients (p=0.025), whereas pulmonary embolism in the No-AT group (p<0.01). (Figure B)

Figure A and B

Conclusions

The AT subgroups showed a comparable TLE success rate, with a higher in-hospital, but non intra-procedural, mortality and more minor bleedings compared to no-ATs. Neither AT regimens or pre-procedural management strategies predicted major complications. AT therapy minimization seems to be safe in patients under chronic AT therapy who undergo TLE. AT do not seem to predict death but identifies a subset of fragile patients with a worse in-hospital TLE outcome.

Acknowledgement/Funding

The following companies have supported the study: Medtronic, Cook Medical, Boston Scientific, Spectranetics and Zoll

P1028Impact of atrial fibrillation ablation procedural volume on complication and recurrence rate across European centers. An ESC EORP registry: atrial fibrillation long-term

Background

Catheter ablation has emerged as an effective therapy in patients with symptomatic and drug refractory atrial fibrillation (AF). Despite high success rates of the method, there is still heterogeneity of outcomes and complication rate across Europe. The impact of the annual procedural volume per center on success and complication rate of AF ablation, based on real-life data, has not been addressed till now.

Purpose

The aim of the study was to investigate if center AF ablation volume might be associated with one-year success or complication rate after the procedure.

Methods

Data for this analysis were extracted from the European AF Ablation Long-Term Study, a prospective registry designed to describe the clinical epidemiology of patients undergoing AF ablation. Based on 25th and 75th percentiles of AF ablation numbers performed, the participating centers were classified into high volume (HV) (≥250 procedures/year), medium volume (MV) (<250 and ≥58/year) and low volume (LV) (<58/year). One-year success was defined as patient survival free from any atrial arrhythmia, from the end of the 3-month blanking period to 12 months following the ablation procedure.

Results

A total of 91 centers in 26 European countries enrolled 3368 patients. There was a significantly higher reporting of cardiovascular complications in LV centers (5.2%), especially pericarditis (0.6%) and cardiac perforation (1.4%), while the HV and MV centers reported cardiovascular complications in 3.0 and 4.3% of cases, respectively (p=0.039). Additionally, stroke incidence after ablation was significantly higher in LV centers (0.5% of cases vs 0% in HV and MV centers, p=0.008). Kaplan-Meier survival analysis based on adjusted data of all complications demonstrated, however, that there was not a significant difference in complication rate according to volume's center (p=0.402, Figure A). One-year success after AF ablation ranged from 77.8% in HV vs 70.5% in LV vs 77.3% in MV centers (p<0.001). Nonetheless, adjusted recurrence rate was not significantly different among centers (p=0.363, Figure B), a result driven by differences both in ablation technical characteristics and risk/severity of cases ablated in different volume centers.

Conclusions

Despite the notion that “the higher, the better”, our results suggest that AF ablation is a safe procedure with high success rates in all European centers, independent of the AF ablation procedural volume. Differences in patients and procedural characteristics may justify the equality of complication and recurrence rate among centers, since expertise level counterbalances the risk of each case.

P4784Efficacy and safety of dronedarone by duration of atrial fibrillation history: a post-hoc analysis of the ATHENA trial

Background

Atrial fibrillation (AF) is known to progress over time and the effectiveness of antiarrhythmic therapy may vary based on the duration of a patient's AF history. Outcomes with dronedarone (DRO) based on duration of AF/atrial flutter (AFL) history have not been previously characterized.

Purpose

To evaluate the efficacy and safety of DRO by time since first known AF/AFL episode in patients studied in the ATHENA trial.

Methods

2859 (61.8%) patients from ATHENA with documented first known AF/AFL episode (of 4628 total patients randomized) were included in the analysis. Among these patients, first AF/AFL episode was reported at <3 months (shorter history), 3 to <24 months (intermediate), and ≥24 months (longer) in 1296 (45.3%), 845 (29.6%) and 718 (25.1%) patients, respectively. AF/AFL recurrence was evaluated in patients in sinus rhythm at baseline by ECG during study visits or symptom recurrence.

Results

Demographics (age, sex) were similar across all groups. Patients with longer AF/AFL history tended to have higher prevalence of coronary heart disease and structural heart disease; and were more likely to have AF/AFL (by 12-lead ECG) at baseline (30%) compared to 26% and 16% for intermediate and shorter history groups. Patients with a longer AF history likely had a prior ablation for AF/AFL (7%) vs patients with an intermediate (2%) or shorter AF/AFL history (1%), and more likely required cardioversion during the study (24%) vs intermediate (17%) and shorter history groups (11%). Outcomes and efficacy are reported in Table 1. Rates of treatment-emergent adverse events (TEAEs), serious TEAEs, permanent drug discontinuations, and deaths were similar across all AF/AFL groups.

Table 1. Outcomes and efficacy summary Relative Risk, dronedarone (DRO) vs placebo (PBO)1 (95% CI)1,2 AF/AFL <3 months AF/AFL 3 to <24 months AF/AFL ≥24 months PBO (n=626) DRO (n=670) PBO (n=429) DRO (n=416) PBO (n=363) DRO (n=355) First CV hospitalization3 or death (any cause) 0.79 (0.65, 0.96) 0.72 (0.56, 0.92) 0.84 (0.66, 1.07) First CV hospitalization 0.78 (0.64, 0.96) 0.70 (0.55, 0.91) 0.82 (0.63, 1.05) Death (any cause) 0.82 (0.54, 1.24) 0.85 (0.43, 1.68) 1.13 (0.61, 2.10) First AF/AFL recurrence4 0.80 (0.65, 0.97) 0.67 (0.53, 0.84) 0.81 (0.65, 1.02) 1Cox regression model. 2On study period, all randomized patients. 3Main reason was AF/other supraventricular rhythm disorders. 4On selected patients in sinus rhythm at baseline (AF/AFL <3 months: PBO n=514, DRO n=529; 3 to <24 months: PBO n=288, DRO n=312; ≥24 months: PBO n=252, DRO n=250). CV = Cardiovascular.

Conclusions

Nearly half the patients in ATHENA had a shorter history (<3 months) of AF/AFL prior to randomization. Patients with a longer history of AF/AFL had a greater burden of AF/AFL based on baseline rhythm status, ablation history, and cardioversions required post randomization. Despite these differences, clinical outcomes, efficacy, and safety of DRO appeared to be generally consistent irrespective of duration of AF/AFL history.

Acknowledgement/Funding

Sanofi, New York, New York, United States of America

An update on atrial fibrillation in 2014: From pathophysiology to treatment

Atrial fibrillation (AF) is the most frequently encountered cardiac arrhythmia. The trigger for initiation of AF is generally an enhanced vulnerability of pulmonary vein cardiomyocyte sleeves to either focal or re-entrant activity. The maintenance of AF is based on a "driver" mechanism in a vulnerable substrate. Cardiac mapping technology is providing further insight into these extremely dynamic processes. AF can lead to electrophysiological and structural remodelling, thereby promoting the condition. The management includes prevention of stroke by oral anticoagulation or left atrial appendage (LAA) occlusion, upstream therapy of concomitant conditions, and symptomatic improvement using rate control and/or rhythm control. Nonpharmacological strategies include electrical cardioversion and catheter ablation. There are substantial geographical variations in the management of AF, though European data indicate that 80% of patients receive adequate anticoagulation and 79% adequate rate control. High rates of morbidity and mortality weigh against perceived difficulties in management. Clinical research and growing experience are helping refine clinical indications and provide better technical approaches. Active research in cardiac electrophysiology is producing new antiarrhythmic agents that are reaching the experimental clinical arena, inhibiting novel ion channels. Future research should give better understanding of the underlying aetiology of AF and identification of drug targets, to help the move toward patient-specific therapy.

Spectrum of clinicopathologic manifestations of arrhythmogenic right ventricular cardiomyopathy/dysplasia: a multicenter study

OBJECTIVES

The aim of the present investigation was to redefine the clinicopathologic profile of arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC), with special reference to disease progression and left ventricular (LV) involvement.

BACKGROUND

Long-term follow-up data from clinical studies indicate that ARVC is a progressive heart muscle disease that with time may lead to more diffuse right ventricular (RV) involvement and LV abnormalities and culminate in heart failure.

METHODS

Forty-two patients (27 male, 15 female; 9 to 65 years old, mean [+/-SD] age 29.6 +/- 18) from six collaborative medical centers, with a pathologic diagnosis of ARVC at autopsy or heart transplantation, and with the whole heart available, were studied according to a specific clinicomorphologic protocol.

RESULTS

Thirty-four patients died suddenly (16 during effort); 4 underwent heart transplantation; 2 died as a result of advanced heart failure; and 2 died of other causes. Sudden death was the first sign of disease in 12 patients; the other 30 had palpitations, with syncope in 11, heart failure in 8 and stroke in 3. Twenty-seven patients experienced ventricular arrhythmias (ventricular tachycardia in 17), and 5 received a pacemaker. Ten patients had isolated RV involvement (group A); the remaining 32 (76%) also had fibrofatty LV involvement that was observed histologically only in 15 (group B) and histologically and macroscopically in 17 (group C). Patients in group C were significantly older than those in groups A and B (39 +/- 15 years vs. 20 +/- 8.8 and 25 +/- 9.7 years, respectively), had significantly longer clinical follow-up (9.3 +/- 7.3 years vs. 1.2 +/- 2.1 and 3.4 +/- 2.2 years, respectively) and developed heart failure significantly more often (47% vs. 0 and 0, respectively). Patients in groups B and C had warning symptoms (80% and 87%, respectively, vs. 30%) and clinical ventricular arrhythmias (73% and 82%, respectively, vs. 20%) significantly more often than patients in group A. Hearts from patients in group C weighed significantly more than those from patients in groups A and B (500 +/- 150 g vs. 328 +/- 40 and 380 +/- 95 g, respectively), whereas hearts from both group B and C patients had severe RV thinning (87% and 71%, respectively, vs. 20%) and inflammatory infiltrates (73% and 88%, respectively, vs. 30%) significantly more often than those from group A patients.

CONCLUSIONS

LV involvement was found in 76% of hearts with ARVC, was age dependent and was associated with clinical arrhythmic events, more severe cardiomegaly, inflammatory infiltrates and heart failure. ARVC can no longer be regarded as an isolated disease of the right ventricle.

Diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy. Task Force of the Working Group Myocardial and Pericardial Disease of the European Society of Cardiology and of the Scientific Council on Cardiomyopathies of the International Society and Federation of Cardiology

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