Occupational radiation exposure of electrophysiology staff with reproductive potential and during pregnancy: an EHRA survey

AIMS

Electrophysiology (EP) is a growing field in cardiology, with an increasing involvement of young people. Nevertheless, concerns about radiation exposure and its impact on reproduction and pregnancy may discourage the choice of an EP career. The study is aimed at investigating the level of awareness and main sources of concern about the effects of radiation on reproductive potential and pregnancy, exploring the safety measures adopted in different EP labs, and verifying the adherence to the current guidelines.

METHODS AND RESULTS

An online survey was conducted using the European Heart Rhythm Association (EHRA) infrastructure from April to June 2022. A total of 252 EP personnel (42% women) participated, from 50 countries and different professional roles. Most participants expressed concerns regarding the effects of radiation on reproductive capacity (67.1%) and offspring diseases (68.2%). Only 37.9% of participants were aware of the EHRA 2017 consensus document about occupational radiation exposure. Most participants (80.9%) considered that occupational radiation during pregnancy is not safe. EP female staff were not allowed to work in the EP lab during pregnancy in 48.1% of cases. Zero-fluoroscopy was the preferred choice to continue working in the EP lab during pregnancy.

CONCLUSION

EP staff, including both men and women, have concerns about the effects of radiation on reproductive capacity. Despite the recommendations issued by international bodies, implementation of the policies regarding pregnancy and occupational radiation exposure is heterogeneous. Zero-fluoroscopy is the preferred approach to ensure safety during pregnancy in the EP lab.

Role of empirical isolation of the superior vena cava in patients with recurrence of atrial fibrillation after pulmonary vein isolation-a multi-center analysis

BACKGROUND

Non-pulmonary vein (PV) triggers play a role in the initiation of atrial fibrillation (AF), with the superior vena cava (SVC) being a common location. The aim of the current study was to investigate a strategy of empirical SVC isolation (SVCI) in addition to re-isolation of PV in patients with recurrence of AF after index PV isolation (PVI).

METHODS

We retrospectively analyzed consecutive patients from two centers with recurrence of AF after index PVI, undergoing a repeat ablation. Whereas only a re-isolation of the PV was intended in patients with reconnections of equal or more than two PV (PVI group), an additional SVCI was aimed for in patients with < 2 isolated PV in addition to the re-isolation of the PV (PVI + group). Analysis was performed as-treated and per-protocol.

RESULTS

Of the 344 patients included in the study (age 60 ± 10 years, 73% male, 66% paroxysmal AF), PVI only was performed in 269 patients (77%) and PVI plus SVCI (PVI +) in 75 patients (23%). Overall, freedom from AF/AT after repeat PVI was 80% (196 patients) in the PVI group and 73% in the PVI + group (p = 0.151). In multivariable Cox regression analysis, presence of persistent AF (HR 2.067 (95% CI 1.389-3.078), p < 0.001) and hypertension (HR 1.905 (95% CI 1.218-2.980), p = 0.005) were identified as only significant predictors of AF/AT recurrence. The per-protocol results did not differ from this observation.

CONCLUSIONS

A strategy of an empirical additional SVCI at repeat PVI ablation for recurrence of AF/AT does not improve outcome compared to a PVI only approach.

COVID-19 pandemic: Impact on the cardiac implantable electronic devices' implantation rates in Croatia

INTRODUCTION

Coronavirus disease 2019 (COVID-19) pandemic has influenced health-care organization worldwide, including management of non-communicable diseases. The aim of this study was to determine the impact of COVID-19 pandemic on cardiac implantable electronic devices' (CIEDs) implantation rates in Croatia.

METHODS

A retrospective, observational, national study was conducted. The data on CIEDs' implantation rates from 20 Croatian implantation centres, between January 2018 and June 2021, were extracted from the national Health Insurance Fund registry. Implantation rates before and after COVID-19 pandemic started, were compared.

RESULTS

The overall numbers of CIED implantations in Croatia during COVID-19 pandemic were not different in comparison to 2 years pre-COVID-19 time (2618 vs. 2807, p = .081). The pacemaker implantation rates decreased significantly (by 45%) during April (122 vs. 223, p < .001) and May 2020 (135 vs. 244, p = .001), as well as during November 2020 (177 vs. 264, p = .003), but significantly increased during summer months 2020 comparing to 2018 and 2019 (737 vs. 497, p<0.001). The ICD implantation rates decreased significantly by 59% in April 2020 (26 vs. 64, p = .048).

CONCLUSION

To the authors best knowledge this is a first study including complete national data on CIED implantation rates and COVID-19 pandemic impact. A significant reduction in number of both pacemaker and ICD implants during specific months of the COVID-19 pandemic was determined. However, afterwards compensation in implants resulted in similar total number when the complete year was evaluated.

Risk factors for internet addiction among Croatian university students during the COVID-19 pandemic

Background

Following the increased internet use due to the COVID-19 pandemic there have been concerns regarding an elevated risk of developing internet addiction (IA). University students are especially prone to develop IA and risk factors for its development in this population during pandemics are not fully investigated nor understood. This study aimed to identify possible risk factors of IA in the studied population during the ongoing pandemic and to compare it with risk factors in pre-pandemic time.

Methods

In April 2016 and April 2022 a validated, anonymous questionnaire that contained questions regarding demographic data, as well as Young's Internet Addiction Test, was self-administered to a cross-faculty representative student sample of the University of Osijek, Croatia.

Results

The study included 1602 university students median age of 21 years (interquartile range 20-22), 34.5% males, and 65.5% females. There was no statistically significant difference in the median age between the two student samples (p = 0.234). The main reason for internet use (social networking and entertainment and online gaming) was considered the significant risk factor for IA in a studied population in pre-pandemic time (the year 2016) and pandemic time (the year 2022) (p < 0.001). In pre-pandemic time the IA was more frequent in males (p = 0.046) while the difference in IA prevalence between sexes did not exist during pandemics (p = 0.160). During pandemics, the students who did not work during their study had higher proportions of IA (p = 0.021) while there was no difference in IA prevalence among students regarding their working status during the study in pre-pandemic time (p = 0.251).

Conclusions

During the COVID-19 pandemic working status of students has been recognized as the new risk factor for IA in the Croatian university students population. Further studies are needed to identify other possible risk factors for IA in the studied population during pandemics.

Key messages

Ablation of residual potentials along the circumferential line reduces acute reconnection in patients undergoing pulmonary vein isolation

Introduction

Acute pulmonary vein (PV) reconnection is frequently encountered in patients with atrial fibrillation (AF) subjected to PV isolation (PVI).

Purpose

In this prospective, multicenter, randomized study, we investigated whether the identification and ablation of sites along the circumferential line with specific electrogram criteria indicative of nontrasmurality, after initial achievement of PVI, reduces acute PV reconnection rate.

Methods

Patients referred for AF ablation at five European centers were enrolled. PVI with antral circumferential isolation of ipsilateral PVs was performed using a contact force sensing ablation catheter delivering 35–40W at the anterior/superior and 30W at the posterior wall with target ablation index of 550 at the anterior wall/roof and 400 at the posterior/inferior segments. Following PVI, mapping with the ablation catheter was performed to identify residual potentials (RP) along the ablation line, defined as bipolar amplitude ≥0.2 mV or 0.1–0.19 mV combined with negative component of the unipolar electrogram as recorded by the 3D mapping system. Ipsilateral PV sets with RPs were randomized to either no further ablation (Group B) or to additional ablation of RPs (Group C). The primary study endpoint was defined as spontaneous or adenosine-mediated recovery of conduction after 30-minute waiting period which was also evaluated in ipsilateral PV sets without residual potentials (Group A).

Results

In total, 109 patients (59.3±10.6 years, 47% hypertension, 9.3% diabetes, left atrial diameter 39.1±4.6mm) were enrolled in the study. After initial isolation of 194 PV pairs, 98 PV pairs had no RPs (Group A) while the remaining 96 with RPs were randomized to either Group B or C (48 PV pairs each). The number of sites with RPs did not differ between groups B and C (4.1±2.5 vs 4.7±3.2, p=0.27). The occurrence of the primary endpoint in Group A was 7.1%. Ablation of residual potentials resulted in significant reduction of spontaneous or adenosine mediated reconnection (14.6% vs 47.9%, p&lt;0.001).

Conclusion

Following initial PVI achievement, ablation of RPs along the antral circumferential line reduces spontaneous or adenosine-mediated acute PV reconnection rate in patients undergoing first-time AF ablation. Therefore, scanning of the PVI line in search of weak links with specific electrogram criteria indicative of nontrasmurality, and subsequent deployment of bonus lesions, could represent a convenient and practical way to reduce acute PV reconnection. Further studies are required to assess long term effects on AF recurrence rates.

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis: The AVATAR Trial

BACKGROUND

Surgical aortic valve replacement (SAVR) represents a class I indication in symptomatic patients with severe aortic stenosis (AS). However, indications for early SAVR in asymptomatic patients with severe AS and normal left ventricular function remain debated.

METHODS

The AVATAR trial (Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis) is an investigator-initiated international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm² with aortic jet velocity >4 m/s or a mean transaortic gradient ≥40 mm Hg), and with normal left ventricular function. Negative exercise testing was mandatory for inclusion. The primary hypothesis was that early SAVR would reduce the primary composite end point of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with a conservative strategy according to guidelines. The trial was designed as event-driven to reach a minimum of 35 prespecified events. The study was performed in 9 centers in 7 European countries.

RESULTS

Between June 2015 and September 2020, 157 patients (mean age, 67 years; 57% men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Follow-up was completed in May 2021. Overall median follow-up was 32 months: 28 months in the early surgery group and 35 months in the conservative treatment group. There was a total of 39 events, 13 in early surgery and 26 in the conservative treatment group. In the early surgery group, 72 patients (92.3%) underwent SAVR with operative mortality of 1.4%. In an intention-to-treat analysis, patients randomized to early surgery had a significantly lower incidence of primary composite end point than those in the conservative arm (hazard ratio, 0.46 [95% CI, 0.23-0.90]; P=0.02). There was no statistical difference in secondary end points, including all-cause mortality, first heart failure hospitalizations, major bleeding, or thromboembolic complications, but trends were consistent with the primary outcome.

CONCLUSIONS

In asymptomatic patients with severe AS, early surgery reduced a primary composite of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with conservative treatment. This randomized trial provides preliminary support for early SAVR once AS becomes severe, regardless of symptoms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02436655.

Adherence to the 4S-AF Scheme in the Balkan region: Insights from the BALKAN-AF survey

BACKGROUND

The 4S-AF scheme includes stroke risk, symptoms, severity of burden, and substrate severity domain.

AIM

We aimed to assess the adherence to the 4S-AF scheme in patients classified according to stroke risk in post hoc analysis of the BALKAN-AF dataset.

METHODS

A 14-week prospective enrolment of consecutive patients with electrocardiographically documented atrial fibrillation (AF) was performed in seven Balkan countries from 2014 to 2015.

RESULTS

Low stroke risk (CHA2DS2-VASc score, 0 in males or 1 in females) was present in 162 (6.0%) patients. 2 099 (77.4%) patients had CHA2DS2-VASc score ≥3 in females or ≥2 in males (high stroke risk), and 613 (22.6%) had CHA2DS2-VASc score <3 in females or <2 in males. Seventy-five (46.3%) patients with low stroke risk and 1555 (74.1%) patients with high stroke risk were prescribed oral anticoagulants (OAC). Two thousand six hundred and seventy-seven (98.6%) had data on European Heart Rhythm Association (EHRA) class. Among 2099 patients with high stroke risk, 703 (33.4%) had EHRA class ≥3. Two hundred and seven (29.4%) patients with EHRA class ≥3 and high stroke risk were offered rhythm control; 620 (55.2%) of individuals with first-diagnosed or paroxysmal AF with high stroke risk were offered rhythm control. Two or more comorbidities occurred in 1927 (91.8%) patients with high stroke risk.

CONCLUSIONS

OAC overuse was observed in patients with low stroke risk, whilst OAC underuse was evident in those with high risk of stroke. The percentage of highly symptomatic patients with high risk of stroke who were offered a rhythm control strategy was low.

Impact of multimorbidity and polypharmacy on the management of patients with atrial fibrillation: insights from the BALKAN-AF survey

OBJECTIVE

We investigated the impact of multimorbidity and polypharmacy on the management of atrial fibrillation (AF) patients in clinical practice and assessed factors associated with polypharmacy and oral anticoagulation (OAC) use in AF patients with multimorbidity and polypharmacy.

METHODS

A 14-week prospective study of consecutive non-valvular AF patients was performed in seven Balkan countries.

RESULTS

Of 2712 consecutive patients, 2263 patients (83.4%) had multimorbidity (AF + ≥2 concomitant diseases) and 1505 patients (55.5%) had polypharmacy. 1416 (52.2%) patients had both multimorbidity and polypharmacy. Overall, 1164 (82.2%) patients received OAC, 200 (14.1%) patients received antiplatelet drugs alone and 52 (3.7%) patients had no antithrombotic therapy (AT). Non-emergency centre and paroxysmal AF were significantly associated with OAC non-use in patients with multimorbidity, whilst age ≥80 years and non-emergency centre were identified to be independent predictors of OAC non-use in patients with polypharmacy.

CONCLUSIONS

Multimorbidity and polypharmacy were common among AF patients in our study. AT was suboptimal and approximately 18% of multimorbid patients with polypharmacy were not anticoagulated. Pattern of AF and non-emergency centre were associated with OAC non-use in AF patients with multimorbidity, whilst non-emergency centre and age ≥80 years were associated with OAC non-use in AF patients with polypharmacy. Key Message Multimorbidity and polypharmacy are common among patients with AF. Antithrombotic therapy was suboptimal in AF patients with multimorbidity and polypharmacy. Approximately, 18% of multimorbid patients with polypharmacy were not anticoagulated.

Initial rhythm control with cryoballoon ablation vs drug therapy: Impact on quality of life and symptoms

BACKGROUND

Cryoballoon ablation (CBA) as a first-line rhythm control strategy is superior to antiarrhythmic drugs (AADs) for preventing atrial fibrillation (AF) recurrence; the impact of first-line CBA on quality of life (QoL) and symptoms has not been well characterized.

METHODS

Patients aged 18 to 75 with symptomatic paroxysmal AF naïve to rhythm control therapy were randomized (1:1) to CBA (Arctic Front Advance, Medtronic) or AAD (Class I or III). Symptoms and QoL were assessed at baseline, 1, 3, 6, 9, and 12 months using the EHRA classification and Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) and SF-36v2 questionnaires. Symptomatic palpitations were evaluated via patient diary.

RESULTS

Overall, 107 patients were randomized to CBA and 111 to AAD; crossovers occurred in 9%. Larger improvements in the AFEQT summary, subscale and treatment satisfaction scores were observed at 12 months with CBA vs AAD (all P <0.05). At 12 months, the mean adjusted difference in the AFEQT summary score was 9.9 points higher in the CBA group (95% CI: 5.5 -14.2, P <0.001). Clinically important improvements in the SF-36 physical and mental component scores were observed at 12 months in both groups, with no significant between group differences at this timepoint. In the CBA vs AAD group, larger improvements in EHRA class were observed at 6, 9 and 12 months (P <0.05) and the incidence rate of symptomatic palpitations was lower (4.6 vs 15.2 days/year post-blanking; IRR: 0.30, P <0.001).

CONCLUSIONS

In patients with symptomatic AF, first-line CBA was superior to AAD for improving AF-specific QoL and symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT01803438.

Antivaccination attitudes and intention to take COVID-19 vaccine in Croatian adult population

Background

COVID-19 vaccine is an effective choice to stop the pandemic. To improve COVID-19 vaccination coverage the better understanding of factors influencing individual intention of vaccination is needed. Antivaccination attitudes (AAs) are important predictors of vaccination behaviour. The aim of this study was to investigate the intention to take COVID-19 vaccine in Croatian adult population and to evaluate factors that influence such intention with emphasis on AAs.

Methods

This cross-sectional questionnaire study was conducted during the June 2020 to December 2020 in convenient sample of adults from Split-Dalmatia County at the primary health care setting. Vaccination Attitudes Examination scale (VAX) was used to assess AAs.

Results

The study sample consisted of 632 subjects (52.7% males and 47.3% females). The median age of all subjects was 38.0 (interquartile range (IQR) 29.0 - 48.0) years. The overall prevalence of intention to take COVID-19 vaccine was 46.8%. Males and subjects living with the partner more frequently expressed intention to take COVID-19 vaccine (P = 0.001 and P = 0.015 respectively). The study revealed fair negative correlation between AAs and intention to take COVID-19 vaccine (rho=-0.453; P < 0.001). Subjects who did not intend to take COVID-19 vaccine demonstrated larger mistrust of vaccine benefits, more worries over unforeseen future effects, more concerns about commercial profit and larger preference for natural immunity (P < 0.0001, P < 0.0001, P < 0.0001, P < 0.0001, respectively).

Conclusions

The study showed fairly low proportion of subjects who intended to take COVID-19 vaccine. The study revealed that gender, marital status, and AAs are good predictors of intention to take COVID-19 vaccine in study population. The good predictors of intention to take COVID-19 vaccine in Croatian adult population should be considered during COVID-19 vaccination popularization strategies development.

Key messages

The structured communication campaigns on COVID-19 and COVID-19 vaccines should be developed and directed specifically to all target groups for vaccination.

Understanding the factors that could improve the acceptance of COVID-19 vaccination is crucial to design effective vaccination program.

Attitudes towards vaccination among Croatian high school students

Background

Due to the success of immunization, most of young people have little experience with vaccine preventable diseases. This inexperience may increase vaccine hesitancy in this population subgroup which can potentially jeopardize population vaccination coverage. Understanding young peoples' attitudes towards vaccination is important for vaccination uptake. The aim of this study was to evaluate attitudes towards vaccination among Croatian high school students.

Methods

This online cross-sectional questionnaire study was conducted during the January 2021 to April 2021 in convenient sample of high school students from north-western part of Croatia. Vaccination Attitudes Examination scale (VAX) was used to assess antivaccination attitudes in study population.

Results

The study included 1012 high school students; 29.2% males and 70.8% females; median age 17.0 (interquartile range (IQR) 17.0 - 18.0) years. Overall value of the VAX score in study sample was 50.4±11.1. Female students had more negative attitudes towards vaccination in comparison to male students (P = 0.001). When analysing differences between female and male students according to the VAX scale subcategories the study revealed that female students demonstrated more worries over unforeseen future effects of the vaccination (P &lt; 0.001) while there were no differences between females and males according to the mistrust of vaccine benefits, concerns about commercial profit and preference for natural immunity (P = 0.155, P = 0.157 and P = 0.142, respectively).

Conclusions

The study revealed rather high antivaccination attitudes among Croatian high school students as measured by VAX score. Further studies are needed to better understand factors that influence such attitudes in study population because programs directed towards changing antivaccination attitudes in order to be efficient need to successfully tackle all of those factors.

Key messages

Public health interventions directed towards suppression of antivaccination movement should more involve younger population subgroups, such as elementary and high school students. Positive attitudes towards vaccination in younger population subgroups are one of the crucial preconditions for adequate vaccination coverage.

Croatian blood collection system amid the COVID-19 pandemic

Background

Croatian blood collection system is based on voluntary donation, according to the recommendations of the World Health Organisation and the Council of Europe. The ongoing COVID-19 pandemic has influenced all the dimensions of human lives and the functional pattern of the health care systems in the whole world. The aim of this study was to investigate the influence of ongoing COVID-19 pandemic on Croatian blood collection system and to evaluate the main factors that influence voluntary blood donation practice in blood donors (BDs).

Methods

This cross-sectional questionnaire study was conducted in convenient sample of voluntary BDs from Split-Dalmatia County during the May 2020 to December 2020.

Results

The study sample consisted of 479 regular BDs, 88.5% males and 11.5% females, mean age 39.8±10.8 years. Majority of them had high school education and living with the partner (67.4% and 74.5%, respectively). During COVID-19 pandemic 71.0% of them continued with regular donations while 29% of them postponed their donation. According to the BDs knowledge regarding COVID-19 infection there were 88.9% of those with unsatisfactory and only 11.1% of those with satisfactory knowledge regarding this infection. The study revealed that females, BDs living alone and younger BDs (aged 18 to 43 years) had more frequently postponed blood donation during COVID-19 pandemic (P < 0.0001, P = 0.004 and P = 0.017, respectively). The study further showed that there was no correlation between BDs knowledge about COVID-19 infection and their blood donation practice during ongoing pandemic.

Conclusions

The study revealed that ongoing COVID-19 pandemic impacted the Croatian blood collection system via reduction in the practice of voluntary blood donations. Sociodemographic characteristics of BDs were the main factors that influence Croatian BDs voluntary blood donation practice during pandemic while their knowledge about COVID-19 infection was not correlated with their behaviour.

Key messages

The sustainability of the health care system during a pandemic depends significantly on the blood supply, which is why it is necessary to ensure that blood collection system is continually maintained.

The knowledge of blood donors about COVID-19 infection needs to be improved in order to prevent spreading of the infection generally and especially within this highly important population subgroup.

Adherence to the 4S-AF Scheme in the Balkan region: insights from the BALKAN-AF survey

Background

Current European Society of Cardiology guidelines on atrial fibrillation (AF) propose a structured characterization of AF in order to facilitate the evaluation of patients by physicians at all healthcare levels. The 4S-AF structured scheme includes four domains: stroke risk, symptoms, severity of AF burden and substrate severity.

Purpose

To evaluate the adherence to the 4S-AF scheme in patients with high risk of stroke (CHA2DS2-VASc score ≥3 in females or ≥2 in males) in the post-hoc analysis of the BALKAN-AF dataset.

Methods

Prospective enrolment of consecutive patients with electrocardiographically documented AF was conducted in seven Balkan countries.

Results

Of the 2,712 enrolled patients, 2,712 (100.0%) had data on CHA2DS2-VASc score. 162 (6.0%) had truly low risk of stroke (CHA2DS2-VASc score of 0 in males and 1 in females). 2099 (77.4%) of patients had high risk of stroke and 613 (22.6%) individuals had low or intermediate risk of stroke (CHA2DS2-VASc score &lt;3 in females or &lt;2 in males). 75 (46.3%) of patients with truly low stroke risk and 1555 (74.1%) of patients with high risk of stroke were offered oral anticoagulants (OAC).

Of the 2,712 patients, 2,677 (98.7%) had data on European Heart Rhythm Association (EHRA) symptom score. Among 2,099 patients with high risk of stroke, 703 (33.4%) individuals had EHRA symptom score of 3 or 4. 207 (29.4%) of patients with EHRA symptom score of 3 or 4 and high risk of stroke were offered rhythm control strategy.

620 (55.2%) of patients with first diagnosed AF or paroxysmal AF with high risk of stroke were offered rhythm control strategy.

1927 (91.8%) of patients with high risk of stroke had ≥2 comorbidities. Mean left atrial diameter in patients with high risk of stroke was 46.5±7.8 mm.

Conclusions

OAC overuse was seen in patients with truly low stroke risk, whist OAC underuse was evident in patients with high risk of stroke. The proportion of highly symptomatic patients (EHRA 3 or 4) with high risk of stroke who were offered rhythm control strategy was low. The proportion of patients with first diagnosed AF or paroxysmal AF with high risk of stroke who received rhythm control was small. The majority of AF patients with high risk of stroke had ≥2 comorbidities. Overall, treatment decision-making was not based on the 4S-AF scheme.

Funding Acknowledgement

Type of funding sources: None.

Prospective Evaluation of a Standardized Screening for Atrial Fibrillation after Ablation of Cavotricuspid Isthmus Dependent Atrial Flutter

Aims: We aimed to prospectively investigate the effectiveness of a standardized follow-up for AF-detection after common atrial flutter (cAFL) ablation. Methods: A total of 309 patients after cAFL ablation without known AF, from 5 centers, and at least one completed, standardized follow-up at 3, 6 and 12 months, including a 24 h Holter-electrocardiogram (ECG), were included. The primary outcome was incident atrial fibrillation (AF), or atrial tachycardia (AT). Predictors were investigated by Cox proportional-hazards models. Results: The mean age was 67.9 years; 15.2% were female and the mean CHA₂DS₂-VASc (Congestive heart failure, Hypertension, Age, Diabetes, Stroke, Vascular disease, Sex category) score was 2.4 points. The great majority of patients (90.3%) were anticoagulated. Over a mean follow-up of 12.2 months with a standardized approach, AF/AT was detected in 73 patients, corresponding to 11.7% at 3 months, 18.4% at 6 months and 28.2% at 12 months of follow-up. AF was found in 64 patients, AT in 9 and both in 2 patients. Occurrence of AF was recorded in 40 (60.6%) patients by Holter-ECG and in the remaining 26 (39.4%) by clinical follow-up only. There was no difference in male versus female (p = 0.08), or in younger versus older patients (p = 0.96) for AF/AT detection. Only coronary artery disease (hazard ratio [95% confidence intervals] 1.03 [1.01–1.05], p = 0.01) was associated with the primary outcome. Conclusions: AF or AT was detected in a large proportion of cAFL patients after cavotricuspid-isthmus (CTI) ablation, using a standardized follow-up over 1 year. This standardized screening can be easily implemented with high patient acceptance. The high proportion of post-ablation AF needs to be taken into consideration when deciding on long-term oral anticoagulation.

Cryoballoon ablation vs. antiarrhythmic drugs: first-line therapy for patients with paroxysmal atrial fibrillation

AIMS

Treatment guidelines for patients with atrial fibrillation (AF) suggest that patients should be managed with an antiarrhythmic drug (AAD) before undergoing catheter ablation (CA). This study evaluated whether pulmonary vein isolation employing cryoballoon CA is superior to AAD therapy for the prevention of atrial arrhythmia (AA) recurrence in rhythm control naive patients with paroxysmal AF (PAF).

METHODS AND RESULTS

A total of 218 treatment naive patients with symptomatic PAF were randomized (1 : 1) to cryoballoon CA (Arctic Front Advance, Medtronic) or AAD (Class I or III) and followed for 12 months. The primary endpoint was ≥1 episode of recurrent AA (AF, atrial flutter, or atrial tachycardia) >30 s after a prespecified 90-day blanking period. Secondary endpoints included the rate of serious adverse events (SAEs) and recurrence of symptomatic palpitations (evaluated via patient diaries). Freedom from AA was achieved in 82.2% of subjects in the cryoballoon arm and 67.6% of subjects in the AAD arm (HR = 0.48, P = 0.01). There were no group differences in the time-to-first (HR = 0.76, P = 0.28) or overall incidence [incidence rate ratio (IRR)=0.79, P = 0.28] of SAEs. The incidence rate of symptomatic palpitations was lower in the cryoballoon (7.61 days/year) compared with the AAD arm (18.96 days/year; IRR = 0.40, P < 0.001).

CONCLUSIONS

Cryoballoon CA was superior to AAD therapy, significantly reducing AA recurrence in treatment naive patients with PAF. Additionally, cryoballoon CA was associated with lower symptom recurrence and a similar rate of SAEs compared with AAD therapy.

Current perspectives on wearable rhythm recordings for clinical decision-making: the wEHRAbles 2 survey

Novel wearable devices for heart rhythm analysis using either photoplethysmography (PPG) or electrocardiogram (ECG) are in daily clinical practice. This survey aimed to assess impact of these technologies on physicians' clinical decision-making and to define, how data from these devices should be presented and integrated into clinical practice. The online survey included 22 questions, focusing on the diagnosis of atrial fibrillation (AF) based on wearable rhythm device recordings, suitable indications for wearable rhythm devices, data presentation and processing, reimbursement, and future perspectives. A total of 539 respondents {median age 38 [interquartile range (IQR) 34-46] years, 29% female} from 51 countries world-wide completed the survey. Whilst most respondents would diagnose AF (83%), fewer would initiate oral anticoagulation therapy based on a single-lead ECG tracing. Significantly fewer still (27%) would make the diagnosis based on PPG-based tracing. Wearable ECG technology is acceptable for the majority of respondents for screening, diagnostics, monitoring, and follow-up of arrhythmia patients, while respondents were more reluctant to use PPG technology for these indications. Most respondents (74%) would advocate systematic screening for AF using wearable rhythm devices, starting at patients' median age of 60 (IQR 50-65) years. Thirty-six percent of respondents stated that there is no reimbursement for diagnostics involving wearable rhythm devices in their countries. Most respondents (56.4%) believe that costs of wearable rhythm devices should be shared between patients and insurances. Wearable single- or multiple-lead ECG technology is accepted for multiple indications in current clinical practice and triggers AF diagnosis and treatment. The unmet needs that call for action are reimbursement plans and integration of wearable rhythm device data into patient's files and hospital information systems.

Differences in activated clotting time and total unfractionated heparin dose during pulmonary vein isolation in patients on different anticoagulation therapy

Background

Periprocedural pulmonary vein isolation (PVI) anticoagulation requires balancing between bleeding and thromboembolic risk. Intraprocedural anticoagulation is monitored by activated clotting time (ACT) with target value >300 s, and there are no guidelines specifying an initial unfractionated heparin (UFH) dose.

Methods

We aimed to assess differences in ACT values and UFH dosage during PVI in patients on different oral anticoagulants. We conducted an international, multi‐center, registry‐based study. Consecutive patients with atrial fibrillation (AF) undergoing PVI, on uninterrupted anticoagulation therapy, were analyzed. Before transseptal puncture, UFH bolus of 100 IU/kg was administered regardless of the anticoagulation drug.

Results

Total of 873 patients were included (median age 61 years, IQR 53–66; female 30%). There were 248, 248, 189, 188 patients on warfarin, dabigatran, rivaroxaban, and apixaban, respectively. Mean initial ACT was 257 ± 50 s, mean overall ACT 295 ± 45 s and total UFH dose 158 ± 60 IU/kg. Patients who were receiving warfarin and dabigatran compared to patients receiving rivaroxaban and apixaban had: (i) significantly higher initial ACT values (262 ± 57 and 270 ± 48 vs. 248 ± 42 and 241 ± 44 s, p < .001), (ii) significantly higher ACT throughout PVI (309 ± 46 and 306 ± 44 vs. 282 ± 37 and 272 ± 42 s, p < .001), and (iii) needed lower UFH dose during PVI (140 ± 39 and 157 ± 71 vs. 171 ± 52 and 172 ± 70 IU/kg).

Conclusion

There are significant differences in ACT values and UFH dose during PVI in patients receiving different anticoagulants. Patients on warfarin and dabigatran had higher initial and overall ACT values and needed lower UFH dose to achieve adequate anticoagulation during PVI than patients on rivaroxaban and apixaban.

Symptom management strategies: Rhythm vs rate control in patients with atrial fibrillation in the Balkan region: Data from the BALKAN-AF survey

BACKGROUND

Symptom-focused management is one of the cornerstones of optimal atrial fibrillation (AF) therapy.

OBJECTIVES

To evaluate the use of rhythm control and rate control strategy. Second, to identify predictors of the use of amiodarone in patients with rhythm control and of the use of rhythm control strategy in patients with paroxysmal AF in the Balkans.

METHODS

Prospective enrolment of consecutive patients from seven Balkan countries to the BALKAN-AF survey was performed.

RESULTS

Of 2712 enrolled patients, 2522 (93.0%) with complete data were included: 1622 (64.3%) patients were assigned to rate control strategy and 900 (35.7%) to rhythm control. Patients with rhythm control were younger, more often hospitalised for AF and with less comorbidities (all P < .05) than those with rate control. Symptom score [European Heart Rhythm Association (EHRA)] was not an independent predictor of a rhythm control strategy [odds ratio (OR) 0.99, 95% confidence interval (CI) 0.90-1.10, P = .945]. The most commonly chosen antiarrhythmic agents were amiodarone (49.7%), followed by propafenone (24.3%).

CONCLUSION

More than one-third of patients in the BALKAN-AF survey received a rhythm control strategy, and these patients tended to be younger with less comorbidities than those managed with rate control. EHRA symptom score is not significantly associated with rhythm control strategy. The most commonly used antiarrhythmic agents were amiodarone, followed by propafenone.

Impact of initial rhythm control with cryoballoon ablation versus drug therapy on atrial fibrillation recurrence and quality of life: results from the Cryo-FIRST study

Funding Acknowledgements

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

OnBehalf

The Cryo-FIRST Investigators

Background

Cryoballoon ablation (CBA) as a first-line rhythm control strategy is superior to antiarrhythmic drugs (AADs) for preventing atrial arrhythmia recurrence; however, the impact of first-line CBA specifically on atrial fibrillation (AF) recurrence and quality of life (QoL) has not been well characterized.

Purpose

To compare AF recurrence and QoL following first-line CBA vs. AAD therapy in patients with paroxysmal AF within the CryoFIRST trial (NCT01803438).

Methods

Patients with recurrent symptomatic paroxysmal AF who had not been administered class I or III AAD therapy for &gt;48 hours were enrolled at 18 sites in 9 countries. Patients were randomized (1:1) to CBA or AAD treatment (Class I or III). Subjects were followed by 7-day Holter at 1, 3, 6, 9, and 12 months. Time-to-first AF recurrence outside of a 90-day blanking period was estimated by Kaplan-Meier analysis.  QoL was evaluated using the Atrial Fibrillation Effect on Quality of Life (AFEQT) and 36-Item Short Form Health Survey (SF-36) v2 questionnaires.

Results

Of the 218 randomized subjects, 187 (86%) completed the 12-month follow-up. By intention-to-treat (ITT) analysis, freedom from AF after blanking was achieved in 86.6% in the CBA and 74.5% in the AAD group (p = 0.023).  There was no difference in the time-to-first serious adverse event between groups. In total, 84.3% of patients in the CBA vs. 75.0% of patients in the AAD arm had a clinically important improvement (≥5 points) in the AFEQT summary score.  The adjusted mean difference in the AFEQT summary score at 12 months was 9.9 points higher in the CBA group (95% CI: 5.5-14.2; P &lt; 0.001).  All AFEQT subscale scores were more favorable in the CBA vs. AAD group at 12 months.  There were no significant group differences in any of the SF-36 health domain scores at 12 months in the ITT analysis.  In the per-protocol analysis, clinically important and significant group differences in favor of CBA were observed at 12 months for 3 of 8 SF-36 health domain scores (physical functioning, general health and social functioning).

Conclusion

CBA is superior to AAD for preventing AF recurrence and improving AF-specific QoL in patients with paroxysmal AF. AFEQT Scores at Baseline and 12 MonthsAFEQT Score, Mean ± Standard DeviationCBAAADAdjusted Mean Difference at 12 Months (CBA vs. AAD)p-valueBaseline12 MonthsBaseline12 MonthsDaily Activities65.3 ± 25.887.8 ± 17.161.0 ± 27.976.6 ± 25.48.9 (3.2-14.6)0.002Symptoms59.9 ± 24.888.8 ± 15.658.4 ± 25.280.9 ± 22.27.1 (1.5-12.7)0.014Treatment Concern59.9 ± 23.189.8 ± 14.060.4 ± 24.577.7 ± 22.212.7 (7.9-17.5)&lt;0.001AFEQT, Atrial Fibrillation Effect on Quality of Life questionnaire. CBA, cryoballoon ablation. AAD antiarrhythmic drug.Abstract Figure. Freedom From Atrial Fibrillation

Quality indicators in the management of atrial fibrillation: the BALKAN-AF survey

BACKGROUND

The implementation of quality indicators in the atrial fibrillation (AF) care should be considered to improve quality of management and patient outcome.

METHODS

In the post-hoc analysis of the BALKAN-AF dataset, we assessed concordance with quality indicators for AF management. Available domains for AF management [patient assessment (baseline), anticoagulation, rate control strategy, rhythm control strategy and risk factor management] were identified and assessed at baseline visit.

RESULTS

Among 132 patients with a CHA₂DS₂-VASc score of 0 (men) or 1 (women), 75 (56.8%) were prescribed oral anticoagulation (OAC). Of 2539 patients with a CHA₂DS₂-VASc score ≥ 1 for men and ≥ 2 for women, 1890 (74.4%) were prescribed OAC. Among 1088 patients with permanent AF, 110 (10.1%) individuals were prescribed antiarrhythmic drugs (AADs). Of 1616 patients with structural heart disease, 37 (2.2%) were prescribed class IC AADs. Of 1624 patients with paroxysmal or persistent AF, 59 (3.6%) were offered catheter ablation. Among 2712 AF patients, 2121 (78.2%) had hypertension, 671 (24.7%) were obese, 53 (2.0%) had obstructive sleep apnoea, 110 (4.0%) had alcohol abuse and 340 (12.5%) were smokers.

CONCLUSIONS

In the BALKAN-AF cohort, the use of OAC for stroke prevention was poorly associated with patients stroke risk. The use of AADs in patients with permanent AF was low. The prescription of class IC AADs to patients with structural heart disease was infrequent. A large proportion of AF patients had their modifiable risk factors identified.

Quality of life measured in first-line therapy during the Cryo-FIRST study: a comparison between cryoballoon catheter ablation versus antiarrhythmic drug therapy

Background

By consensus statements, catheter ablation is a recommended treatment for patients with symptomatic drug-refractory paroxysmal atrial fibrillation (AF), as patients try to alleviate the burdensome AF symptoms that reduce the Quality of Life (QoL). Yet, first-line treatment of symptomatic patients via catheter ablation prior to initiation of antiarrhythmic drugs (AADs) is only a reasonable alternative (Class IIa). Clearly, more clinical data is necessary that compares catheter ablation to AAD therapy in treatment naïve patients.

Purpose

The Cryo-FIRST trial was designed to compare AAD treatment against pulmonary vein isolation (PVI) while using a cryoballoon catheter (Arctic Front Advance; Medtronic, Inc.). This current data analysis examines the QoL endpoints when comparing AADs to cryoballoon ablation in patients with symptomatic treatment naïve paroxysmal AF.

Methods

This randomized multicenter trial enrolled 220 patients from 18 sites in 9 countries (Europe, Australia, and Latin America) in a prospective open-blinded endpoint study design. Patients had not been administered a class I or III AAD for longer than 48 hours for inclusion into the study. Subjects were randomized (1:1) into a cohort that was administered AAD therapy or a cohort that received PVI via cryoablation. The prespecified QoL endpoint at 12 months was measured using the Atrial Fibrillation Effect on Quality of Life (AFEQT) scores, and QoL recordings were taken at baseline, 1, 3, 6, 9, and 12 months following the index treatment.

Results

Of the 218 patients randomized (age 52±13 years, 68% male) 86% completed the 12-month follow-up. Crossovers occurred in 9% of subjects (N=20), including: 1 subject in the cryoablation arm and 19 subjects in the AAD arm. At 12 months, 86.5% of the patients in the cryoablation arm and 70.4% of the patients in the AAD arm where without symptoms (EHRA score 1). The mean AFEQT summary score was more favorable in the catheter ablation group compared to the drug therapy group at 12 months (88.9 vs. 78.1 points, respectively). The adjusted difference was 9.9 points (95% CI: 5.5–14.2; P&lt;0.0001).

Conclusions

Cryoballoon ablation resulted in a significant improvement in QoL at 12 months compared to AAD therapy in treatment naïve patients with first-line symptomatic paroxysmal AF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic International Trading Sàrl

Treatment implications of renal disease in patients with atrial fibrillation: The BALKAN-AF survey

BACKGROUND

Atrial fibrillation (AF) often co-exists with renal function (RF) impairment. We investigated the characteristics and management of AF patients across creatinine clearance strata and potential changes in the use of nonvitamin K oral anticoagulants (NOAC) according to different equations for estimation of RF.

METHODS

In this post hoc analysis of the BALKAN-AF survey, patients were classified according to RF (Cockcroft-Gault formula) as: preserved/mildly depressed RF (P-RF) ≥50 mL/min, moderately depressed RF (MD-RF) 30-49 mL/min, and severely depressed RF (SD-RF) <30 mL/min.

RESULTS

Of 2712 enrolled patients, 2062 (76.0%) had data on RF. Patients with SD-RF and MD-RF were older, had higher mean value of European Heart Rhythm Association score, stroke and bleeding risk scores, and more comorbidities than patients with P-RF (all P < .05). They received oral anticoagulants (OAC), AF catheter ablation, and electrical cardioversion less often than those with P-RF (all P < .05). Rate control, no OAC, single-antiplatelet therapy (SAPT) alone, and loop diuretics were more prevalent in patients with SD-RF and MD-RF than in subjects with P-RF (all P < .005). An important change in NOAC therapy could appear in <1% of patients (Modification of Diet in Renal Disease formula) and in <1% of patients (Chronic Kidney Disease Epidemiology Collaboration group formula).

CONCLUSIONS

Patients with SD-RF and MD-RF were older, more symptomatic, had higher stroke and bleeding risk and more comorbidities than those with P-RF. They were less likely to receive OAC and more likely to use rate control strategy, SAPT alone, and no OAC than subjects with P-RF.

P993Incidence of atrial fibrillation early after cavotricuspid isthmus ablation

Background

Atrial fibrillation (AF) is a common finding in patients undergoing cavotricuspid isthmus ablation for isthmus dependent right atrial flutter (RAF). Little is known about the time of its occurrence.

Purpose

We aimed to investigate the incidence of AF early after RAF ablation in a well-defined, prospective cohort.

Methods

A total of 255 participants with RAF ablation from 5 centers and at least one completed follow-up were included. Structured clinical follow-up was performed at 3, 6 and 12 months including a 24 hour Holter-ECG. The endpoint was incidence of AF detected clinically or by Holter-ECG. Risk factors associated with the occurrence of AF were assessed using separate, univariate Cox proportional-hazards models.

Results

Mean age was 67 years, 80% were male and previous episodes of AF were known in 40%. Over a mean follow-up of 7.4 (±4.4) months AF was detected in 35 (13.7%) participants after RAF ablation (Figure A). After 3, 6 and 12 months AF was detected in 18 (7.1%), 30 (11.7%) and 34 (13.3%) patients. No difference in the incidence of AF after RAF ablation was found comparing patients with and without a history of AF (log-rank p value = 0.44) (Figure B). Comparing patients with and without AF during follow-up, there was no difference in age (68 vs 66 years, p = 0.36), sex (69 vs 81% male, p = 0.08), prior heart failure (29 vs 19%, p = 0.20), hypertension (43 vs 38%, p = 0.56) or left atrial volume (46.6 vs 39.6 ml, p = 0.10), but patients with previous AF had a lower left ventricular ejection fraction (LVEF) (45.7 vs 52.3%, p = 0.02). In separate, univariate Cox proportional-hazards models only increasing LVEF (Hazard ratio 0.97, 95% confidence interval (0.95; 0.99, p = 0.02)) was associated with a lower risk of incident AF after RAF ablation, but no other risk factor.

Conclusions

AF occurred in 13.7% of patients early after cavotricuspid isthmus ablation for RAF. There was no difference in the occurrence of AF between patients with and without previously known episodes of AF. Only impaired LVEF was associated with AF occurrence.

Abstract Figure

Cryoballoon catheter ablation versus antiarrhythmic drugs as a first-line therapy for patients with paroxysmal atrial fibrillation: Rationale and design of the international Cryo-FIRST study

BACKGROUND

Radiofrequency current (RFC) catheter ablation for patients with paroxysmal atrial fibrillation (AF) has been shown to be safe and effective in first-line therapy. Recent data demonstrates that RFC ablation provides better clinical outcomes compared to antiarrhythmic drug (AAD) in the treatment of early AF disease. Furthermore, studies comparing RFC and cryoballoon have established comparable efficacy and safety of pulmonary vein isolation (PVI) for patients with symptomatic paroxysmal AF.

OBJECTIVES

The Cryo-FIRST trial was designed to compare AAD treatment against cryoballoon PVI as a first-line therapy in treatment naïve patients with AF. Efficacy and safety will be compared between the two cohorts and amongst subgroups.

METHODS

The primary hypothesis is that cryoablation is superior to AAD therapy. To test this hypothesis, patients will be randomized in a 1:1 design. Using a 90-day blanking period, primary efficacy endpoint failure is defined as (at least) one episode of atrial arrhythmia with a duration >30 sec (documented by 7-day Holter or 12-lead ECG). Secondary endpoints (Quality-of-Life, rehospitalization, arrhythmia recurrence rate, healthcare utilization, and left atrial function) and adverse events will also be evaluated. Study enrollment will include 218 patients in up to 16 centers.

CONCLUSIONS

This study will be a multi-national randomized controlled trial comparing cryoablation against AAD as a first-line treatment in patients with paroxysmal AF. The results may help guide the selection of patients for early AF disease therapy via cryoballoon ablation.

Stroke prevention in elderly patients with non-valvular atrial fibrillation in the BALKAN-AF survey

BACKGROUND

Atrial fibrillation (AF) is common amongst the elderly, but this group tends to be suboptimally treated. Limited data are available on the stroke prevention strategies in the elderly, especially in the Balkan region.

AIM

We investigated the use of oral anticoagulant therapy (OAC) amongst elderly AF patients in clinical practice in the Balkan region.

METHOD

A 12-week prospective snapshot survey (2014-2015) of consecutive non-valvular AF patients was conducted in Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Montenegro, Romania and Serbia. Data were collected via an electronic case report form.

RESULTS

Of 2671 patients, 418 (15.6%) were ≥80 years old. Overall, OAC was used in 1965 patients (73.6%). Compared with younger patients, the elderly (age ≥ 80) had a higher mean CHA₂ DS₂ -VASc score (3.22 ± 1.71 vs 4.89 ± 1.35, P < .001) and more often a HAS-BLED score of ≥3 (n = 198 [47.0%] vs n = 625 [27.3%], P < .001), but were less likely to receive OAC (n = 269 [64.4%] vs n = 1696 [75.3%], odds ratio [OR] 0.91; 95%CI 0.86-0.97, P = .003). There was no significant association between OAC use and mean CHA₂ DS₂ -VASc (OR 0.86; 95%CI 0.75-1.00, P = .053) or HAS-BLED score (OR 1.21; 95%CI 0.81-1.81, P = .349) in the elderly.

CONCLUSION

In the BALKAN-AF Survey, elderly AF patients were less likely to receive the guideline-adherent treatment despite their less favourable risk profile. Since OAC nonuse among the elderly was not associated with increased HAS-BLED score, factors other than patients' risk profile could influence the implementation of guideline-adherent treatment for thromboprophylaxis in the elderly AF patients.

Management of patients with newly-diagnosed atrial fibrillation: Insights from the BALKAN-AF survey

•

23.6% of patients in the survey had newly-diagnosed atrial fibrillation (AF).

•

Those patients had different risk profiles than those with a history of AF.

•

The specificity of the management of first-diagnosed AF patients was presented.

Background

BALKAN-AF evaluated patterns of atrial fibrillation (AF) management in real-world clinical practice in the Balkans. The objectives were: to assess the proportion of patients with first-diagnosed AF in the BALKAN-AF cohort and to compare the management of patients with newly-diagnosed AF and those with previously known AF in clinical practice.

Methods

Consecutive patients from 7 Balkan countries were enrolled prospectively to the snapshot BALKAN-AF survey.

Results

Of 2712 enrolled patients, 2677 (98.7%) with complete data were included. 631 (23.6%) patients had newly-diagnosed AF and 2046 (76.4%) patients had known AF. Patients with newly-diagnosed AF were more likely to be hospitalized for AF and to receive single antiplatelet therapy (SAPT) alone and less likely to receive OACs than those with known AF (all p < 0.001). The use of OAC was not significantly associated with the CHA₂DS₂-VASc (p = 0.624) or HAS-BLED score (p = 0.225) on univariate analysis. Treatment in capital city, hypertension, dilated cardiomyopathy, mitral valve disease, country of residence or rate control strategy were independent predictors of OAC use, whilst non-emergency centre, treatment by cardiologist, paroxysmal AF, palpitations, symptoms attributable to AF (as judged by physician), mean heart rate and AF as the main reason for hospitalization were independent predictors of rhythm control strategy use.

Conclusions

In BALKAN-AF survey, patients with newly-diagnosed AF were more often hospitalized, less often received OAC and were more likely to receive SAPT alone. The use of OAC for stroke prevention has not been driven by the individual patient stroke risk.

Left anterior descending coronary artery dissection during ventricular tachycardia ablation - case report

Fascicular left ventricular tachycardia (VT) is the second most frequent idiopathic left VT in the setting of a structurally normal heart. Catheter ablation is curative in most patients with low complication rates. We report a case of ostial left anterior descending coronary artery (LAD) occlusion during fascicular ventricular tachycardia ablation. Dissection was the most likely cause of LAD obstruction. To the authors' best knowledge, this is the first case reporting selective LAD dissection during electrophysiology study with no left main coronary artery (LMCA) affection.

High-sensitive cardiac troponin T as a predictor of efficacy and safety after pulmonary vein isolation using focal radiofrequency, multielectrode radiofrequency and cryoballoon ablation catheter

Introduction

Myocardial injury markers such as high-sensitive cardiac troponin T (hs-cTnT) and creatine kinase MB (CK-MB) reflects the amount of myocardial injury with ablation. The aim of the study was to identify the value of myocardial injury markers to predict outcomes after pulmonary vein isolation (PVI) using three different ablation technologies.

Methods

Consecutive patients undergoing PVI using a standard 3.5 mm irrigated-tip radiofrequency catheter (RF-group), an irrigated multielectrode radiofrequency catheter (IMEA-group) and a second-generation cryoballoon (CB-group) were analysed. Blood samples to measure injury markers were taken before and 18–24 hours after the ablation. Procedural complications were collected and standardised follow-up was performed. Logistic regression was used to identify predictors of recurrence and complications.

Results

96 patients (RF group: n=40, IMEA-group: n=17, CB-group: n=39) undergoing PVI only were analysed (82% male, age 59±10 years). After a follow-up of 12 months, atrial fibrillation (AF) recurred in 45% in the RF-group, 29% in the IMEA-group and 36% in the CB-group (p=0.492). Symptomatic pericarditis was observed in 20% of patients in the RF-group, 15% in the IMEA-group and 5% in the CB-group (p=0.131). None of the injury markers was predictive of AF recurrence or PV reconnection after a single procedure. However, hs-cTnT was identified as a predictor of symptomatic pericarditis (OR: 1.003 [1.001 to 1.005], p=0.015).

Conclusion

Hs-cTnT and CK-MB were significantly elevated after PVI, irrespective of the ablation technology used. None of the myocardial injury markers were predictive for AF recurrence or PV reconnection, but hs-cTnT release predicts the occurrence of symptomatic pericarditis after PVI.

Reliability of luminal oesophageal temperature monitoring during radiofrequency ablation of atrial fibrillation: insights from probe visualization and oesophageal reconstruction using magnetic resonance imaging

Aims

A current concept to prevent atrio-oesophageal fistula during radiofrequency (RF) catheter ablation of atrial fibrillation is to monitor luminal oesophageal temperature (LET). The objective of this study was to describe the temporal course of LET and to assess the reliability of monitoring the maximal LET during pulmonary vein isolation (PVI) using irrigated multi-electrode (IMEA, nMARQTM) and focal ablation catheters.

Methods and results

We studied 40 patients with LET monitoring during PVI (20 patients using the IMEA and 20 patients using the focal catheter). A linear probe was used and visualized in the 3D mapping system. Left atrial and oesophageal reconstructions from delayed enhanced magnetic resonance imaging were integrated. Analysing 745 temperature profiles, LET >38°C was observed in 48 of 296 (17%) and 44 of 449 (10%) ablations for the IMEA and the focal catheter, respectively (P = 0.012). Temporal latency after interruption of RF energy delivery was observed for both catheters. Time until LET baseline temperature was restored after an increase of >1°C was 100 and 86 s for the IMEA and the focal catheter, respectively (P = 0.183). Imprecise representation of the maximal LET was observed in 24 (60%) and 28 patients (70%) for the left and right PVs, respectively.

Conclusion

Due to the unknown exact lateral position of the LET probe within the oesophagus, the measured temperature does not necessarily reflect the maximal LET. The absence of LET increase does not rule out significant temperature increase within the oesophagus. Consequently, the temperature information of the linear multipolar probe should be used with caution.

Tool for decision-making regarding general evacuation during a rapid river flood

OBJECTIVES

To propose a simple and effective tool for decision-making regarding general evacuation during a rapid river flood.

STUDY DESIGN

Virtual testing of a tool in a real event.

METHOD

A four-component tool was applied to build an alternative scenario of the catastrophic river flood in Obrenovac, Serbia, on May 2014. The components of this tool are: (1) the amount of precipitation above the 95th percentile of all previous measurements; (2) upstream river discharge above the 95th percentile of all previous measurements; (3) upstream river level above the 95th percentile of all previous measurements; and (4) worsening of the hydrometeorological situation in the following 48 h.

RESULTS

In the early morning of 16 May 2014, a rapid river wave flooded 80% of the Obrenovac territory. There were 13 deaths due to drowning. Application of the study tool shows that these lives could have been saved, as the score to recommend general evacuation was reached 1 day before the flooding. The application of this tool to two previous great floods in Serbia shows that the score to recommend general evacuation was reached either 1 day before or on the onset of flash flooding.

CONCLUSIONS

Due to its simplicity, this tool is universally applicable to facilitate decision-making regarding general evacuation during a rapid river flood, and it should be further tested in future similar catastrophes.

Docking-based preliminary study on the interactions of bile acids with drugs at the transporter level in intestinal bacteria

OBJECTIVE

The aim of this study was to estimate the binding-affinities of different bile acids towards drug transporters in Lactobacillus acidophilus and Bifidobacterium longum in order to predict the influence of bile acids and probiotics interactions on drug pharmacokinetics.

MATERIALS AND METHODS

In order to study interactions of bile acids with transporters of intestinal bacteria, molecular-docking step was performed, using SwissDock web-service. For the purpose of comparison, two natural bile acids, cholic acid (CA) and deoxycholic acid (DCA), and one semi-synthetic bile acid, 12-monoketocholic acid (MKC), were studied in parallel. The free-binding energy was used as the main criterion for ranking ligands.

RESULTS

Studied bile acids exhibited different binding affinities towards bacterial transporters with MKC showing the most prominent effect. For the majority of studied transporters, the estimated affinities of bile acids decreased in the following order: MKC-CA-DCA. Namely, 38.7% of examined transport proteins gave the lowest free-binding energy with MKC. The weak inverse relationship between number of hydrogen bonds and estimated free-binding energies was revealed.

CONCLUSIONS

The predominant effect of MKC for the majority of studied transport proteins suggests that keto group at carbon 12 of the steroid core has a significant influence on the properties of MKC and consequently, on interactions with membrane transporters. Present findings might have a role in the prediction of potential influence of bile acids and probiotics on drug pharmacokinetics.

Effective reduction of fluoroscopy duration by using an advanced electroanatomic-mapping system and a standardized procedural protocol for ablation of atrial fibrillation: 'the unleaded study'

AIMS

It is recommended to keep exposure to ionizing radiation as low as reasonably achievable. The aim of this study was to determine whether fluoroscopy-free mapping and ablation using a standardized procedural protocol is feasible in patients undergoing pulmonary vein isolation (PVI).

METHODS AND RESULTS

Sixty consecutive patients were analysed: Thirty consecutive patients undergoing PVI using Carto3 were treated using a standardized procedural fluoroscopy protocol with X-ray being disabled after transseptal puncture (Group 1) and compared with a set of previous 30 consecutive patients undergoing PVI without a specific recommendation regarding the use of fluoroscopy (Group 2). The main outcome measures were the feasibility of fluoroscopy-free mapping and ablation, total fluoroscopy time, total dose area product (DAP), and procedure time. Sixty patients (age 60 ± 10 years, 73% male, ejection fraction 0.55 ± 0.09, left atrium 42 ± 8 mm) were included. In Group 1, total fluoroscopy time was 4.2 (2.6-5.6) min and mapping and ablation during PVI without using fluoroscopy was feasible in 29 of 30 patients (97%). In Group 2, total fluoroscopy time was 9.3 (6.4-13.9) min (P < 0.001). Total DAP was 13.2 (6.2-22.2) Gy*cm(2) in Group 1 compared with 17.5 (11.7-29.7) Gy*cm(2) in Group 2 (P = 0.036). Total procedure time did not differ between Groups 1 (133 ± 37 min) and 2 (134 ± 37 min, P = 0.884).

CONCLUSION

Performing mapping and ablation guided by an electroanatomic-mapping system during PVI without using fluoroscopy after transseptal puncture using a standardized procedural protocol is feasible in almost all patients and is associated with markedly decreased total fluoroscopy duration and DAP.

Analgesic effects of rosemary essential oil and its interactions with codeine and paracetamol in mice

OBJECTIVE

The use of herbal medicinal products in the management of pain has been increasing steadily in recent years, often in combination with conventional analgesics, which can induce significant interactions. In traditional medicine, rosemary was used as mild analgesic, for relieving renal colic pain and dysmenorrhea. The aim of our study was to examine analgesic effects of rosemary essential oil and its pharmacodynamic interactions with codeine and paracetamol in mice.

MATERIALS AND METHODS

The identification and quantification of chemical constituents of the essential oil isolated from air-dried aerial parts of rosemary were carried out by GC/FID and GC/MS. The hot plate test was performed on NMRI mice by placing them individually on hot plate and assessing their response to the thermal stimulus.

RESULTS

In this research, we identified 29 chemical compounds of the studied rosemary essential oil, and the main constituents were 1,8-cineole, camphor, and α-pinene. Administration of investigated essential oil increased significantly the latency time of animal response to heat-induced pain between 20th and 50th minute of the test, when compared to saline-treated group. Rosemary essential oil in the dose of 20 mg/kg was shown to be more efficient than in the dose of 10 mg/kg, in combinations with both codeine and paracetamol.

CONCLUSIONS

Our findings support the use of rosemary in the management of pain and indicate a therapeutic potential of rosemary essential oil in combination with analgesic drugs. The mechanisms involved in analgesic effects of rosemary essential oil and the potential influence on cytochromes and drug metabolism should be more in-depth investigated.

Comparison of different approaches to atrioventricular junction ablation and pacemaker implantation in patients with atrial fibrillation

BACKGROUND

To compare the feasibility and efficiency of atrioventricular junction (AVJ) ablation and device implantation in patients with drug-refractory atrial fibrillation using three different approaches.

METHODS

Sixty-nine patients (57% male; age 72 ± 10; ejection fraction 45 ± 15%) undergoing device implantation and AVJ ablation were retrospectively studied at a tertiary referral center. In 20 patients (29%) AVJ ablation was performed via the femoral vein immediately following device implantation (group 1), whereas 33 patients (48%) underwent a staged procedure with AVJ ablation via the femoral vein >3 weeks after device implantation (group 2). In a third group of 16 patients (23%), AVJ ablation was performed during device implantation through the pocket using the same axillary vein access site (group 3). The main outcome measures were: procedure time, fluoroscopy time, laboratory occupancy time, and success rate.

RESULTS

There was a significant difference in procedure time (118 ± 45 minutes. in group 1, 133 ± 32 minutes in group 2, and 87 ± 26 minutes in group 3, P < 0.001) and the laboratory occupancy time (175 ± 48 minutes in group 1, 200 ± 32 minutes in group 2, and 121 ± 27 minutes in group 3, P < 0.001). There was no difference in fluoroscopy time (group 1: 20 ± 15 minutes, group 2: 27 ± 22 minutes, and group 3: 24 ± 9 minutes P = 0.4). The procedure was successfully completed in all patients, but cross-over to a femoral approach was required in one patient in group 3.

CONCLUSION

The alternative approach of AVJ ablation during permanent pacemaker implantation from the same axillary vein access site is feasible and more efficient compared to the femoral approach.

Persistent Left Superior Vena Cava in Patients Undergoing Cardiac Device Implantation: Clinical and Long-Term Data

Background

Persistent left superior vena cava (LSVC) is a rare congenital venous anomaly that may be found at the time of cardiac device lead insertion.

Methods

In this case series, we present clinical and long-term data of five patients with LSVC who underwent pacemaker (PM) or cardioverter defibrillator (ICD) implantation during the period of 10 years.

Results

Left-sided venous approach was used for device implantation in 3 patients with standard PM indications, whereas a right-sided venous approach and an epicardial approach had to be used in 2 patients who needed an ICD and biventricular PM, respectively. In post implantation period of 44 ± 29 months, one patient died due to stroke, one underwent heart transplantation, and 3 had atrial fibrillation.

Conclusion

The long-term outcome of patients with persistent LSVC and implanted cardiac devices is mostly influenced by the presence of underlying heart disease.

Balkan Endemic Nephropathy Risk Associates to the hs1.2 Ig Enhancer Polymorphism

Balkan Endemic Nephropathy (BEN) is a kidney degenerative disease with a high incidence in the valleys of the Danube and tributary rivers. Many studies describe it as a multifactorial disease. Environmental as well immuno-inflammatory and genetic cofactors have been suggested to trigger the onset of the disease. Recently, high levels of C-reactive protein were demonstrated in BEN patients. We performed this study to evaluate the possible correlation of BEN with the polymorphism of the Ig heavy chain 3'Regulatory Region enhancer hsl.2 that is related to changes of consensus for trans activators binding within the DNA sequence and probably consequently autoimmune and inflammatory diseases. Therefore, we studied three cohorts: 1) 111 control subjects, 2) 95 BEN patients in dialysis therapy and 3) 133 components of a large family “J” in the same geographical area. The allelic frequencies of hsl.2 of BEN patients and family “J” components had similar decrease frequency of allele *1 and increase of allele *2 in respect to the controls. This trend suggests the association of allele *1 as a protective and allele *2 as a risk component for the disease. The presence of a consensus sequence for NF-Kb in the allele *2 may link the polymorphism to the inflammatory activity of BEN. This study supports the presence of an inflammatory pathway in BEN through the involvement of polymorphic enhancer hsl.2 influencing differently binding complexes and consequently the 3D structure of 3' Regulatory Region of IgH. Our work is the first study that clearly links BEN to a gene involved in the regulation of immune response.