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Purpose@#Advanced chronic kidney disease (CKD), including end-stage renal disease (ESRD) on dialysis, increases thromboembolic risk among patients with atrial fibrillation (AF). This study examined the comparative safety and efficacy of direct-acting oral anticoagulant (DOAC) compared to warfarin or no oral anticoagulant (OAC) in AF patients with advanced CKD or ESRD on dialysis. @*Materials and Methods@#Using data from the COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry, 260 non-valvular AF patients with advanced CKD (defined as estimated glomerular filtration rate <30 mL/min per 1.73/m2 ) or ESRD on dialysis were enrolled from June 2016 to July 2020. The study population was categorized into DOAC, warfarin, and no OAC groups; and differences in major or clinically relevant non-major (CRNM) bleeding, stroke/systemic embolism (SE), myocardial infarction/critical limb ischemia (CLI), and death were assessed. @*Results@#During a median 24 months of follow-up, major or CRNM bleeding risk was significantly reduced in the DOAC group compared to the warfarin group [hazard ratio (HR) 0.11, 95% confidence interval (CI) 0.01 to 0.93, p=0.043]. In addition, the risk of composite adverse clinical outcomes (major or CRNM bleeding, stroke/SE, myocardial infarction/CLI, and death) was significantly reduced in the DOAC group compared to the no OAC group (HR 0.16, 95% CI 0.03 to 0.91, p=0.039). @*Conclusion@#Among AF patients with advanced CKD or ESRD on dialysis, DOAC was associated with a lower risk of major or CRNM bleeding compared to warfarin and a lower risk of composite adverse clinical outcomes compared to no OAC.ClinicalTrials.gov (NCT02786095)
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Background and Objectives@#Atrial fibrillation (AF) is associated with decreased cardiac resynchronization therapy (CRT) benefits compared to sinus rhythm (SR). Effective biventricular (BiV) pacing is a determinant of CRT success, but AF can interfere with adequate BiV pacing and affect clinical outcomes. We investigated the effect of device-detected AF on clinical outcomes and optimal BiV pacing in patients with heart failure (HF) treated with CRT. @*Methods@#We retrospectively analyzed 174 patients who underwent CRT implantation between 2012 and 2019 at a tertiary center. The optimal BiV pacing percentage was defined as ≥98%. Device-detected AF was defined as an atrial high-rate episode ≥180 beats per minute lasting more than 6 minutes during the follow-up period. We stratified the patients without preexisting AF at pre-implantation into device-detected AF and no-AF groups. @*Results@#A total of 120 patients did not show preexisting AF at pre-implantation, and 54 had AF. Among these 120 patients, 19 (15.8%) showed device-detected AF during a median follow-up of 25.1 months. The proportion of optimal BiV pacing was significantly lower in the device-detected AF group than in the no-AF group (42.1% vs. 75.2%, p=0.009). The devicedetected AF group had a higher incidence of HF hospitalization, cardiovascular death, and all-cause death than the no-AF group. The device-detected AF and previous AF groups showed no significant differences regarding the percentage of BiV pacing and clinical outcomes. @*Conclusions@#For HF patients implanted with CRT, device-detected AF was associated with lower optimal BiV pacing and worse clinical outcomes than no-AF.
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Background@#The prognostic significance of resting heart rate and its therapeutic target in atrial fibrillation (AF) is uncertain. We sought to investigate the relationship between resting heart rate and cardiovascular outcomes in patients with non-paroxysmal AF (non-PAF). @*Methods@#In this propensity score-weighted, multi-center prospective cohort study, 3217 patients with non-PAF were analyzed. Patients were categorized according to the baseline resting heart rate and cardiovascular outcomes were accessed for a median follow-up of 30 months. The primary outcome was a composite of cardiovascular death, heart failure hospitalization, and myocardial infarction/critical limb ischemia. @*Results@#Freedom from primary outcome was longest among patients with resting heart rate 80–99 beats per minute (bpm) whereas shortest among those with ≤ 59 bpm (weighted log rank, p = 0.008). Compared with heart rate ≥ 100 bpm, resting heart rate 80–99 and 60–79 bpm was associated with reduced risk of primary outcome (weighted hazard ratio [WHR] 0.52, 95% confidence interval [CI] 0.32–0.84, p = 0.008 and WHR 0.58, 95% CI 0.37–0.92, p = 0.021 for heart rate 80–99 and 60–79 bpm, respectively). Using weighted restricted cubic spline curves, there was a U-shaped association between the resting heart rate and primary outcome with reduced risk of primary outcome in heart rate range of 68–99 bpm. This association was maintained regardless of atrioventricular node (AVN) blocker use or persistent/permanent AF (p for interaction 0.767 for AVN blocker use and 0.720 for AF type). @*Conclusion@#Resting heart rate was associated with cardiovascular outcomes in patients with non-PAF and those with resting heart rate between 68 and 99 bpm had lower risk of adverse cardiovascular events regardless of AVN blocker use or persistent/permanent AF.
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Background@#It has become important to identify and manage risk factors for subclinical atrial fibrillation (AF) with an increase in its detection rate. Thus, this research aimed to investigate whether alcohol consumption contrib‑ utes to the development of subclinical AF. @*Methods@#This prospective study enrolled 467 patients without AF from a multicenter pacemaker registry. The incidence of subclinical AF (episodes of atrial rate > 220 beats per minute without symptoms) was compared between alcohol-drinking and non-drinking groups. @*Results@#During followup (median 18 months), the incidence and risk of long-duration atrial high-rate episodes (AHRE) ≥ 24 h were increased in the alcohol group compared to the non-alcohol group [5.47 vs. 2.10 per 100 personyears, adjusted hazard ratio (HR), 2.83; 95% confidence interval (CI), 1.14–7.04; P = 0.03]. After propensity score match‑ ing, the incidence and risk of long-duration AHRE were higher in the alcohol group (6.97 vs. 1.27 per 100 personyears, adjusted HR, 7.84; 95% CI, 1.21–50.93; P = 0.03). The mean burden of long-duration subclinical AF was higher in the alcohol group than in the non-alcohol group (0.18 vs. 1.61% during follow-up, P = 0.08). @*Conclusion@#Alcohol consumption was associated with an increased risk of subclinical AF. Long-duration AHRE inci‑ dence and AHRE burden were higher in alcohol drinkers than in non-drinkers.
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Background@#Traditional right ventricular apical pacing can cause electrical–mechanical dyssynchrony. Therefore, physiological conduction system pacing was considered and became the reason for developing His bundle pacing (HBP). Recently, left bundle branch area pacing (LBBAP) has been implemented, which overcomes the shortcomings of HBP. Most initial large LBBAP studies reported that LBBAP was achieved through a lumenless pacing lead (LLL) with a fixed helix design; however, it is unavailable in Korea. LBBAP delivery sheaths using a conventional standard styletdriven pacing lead (SDL) with an extendable helix design are currently available in Korea. In this review, we describe the methods and procedural skills required to perform the LBBAP using conventional SDL.Main body LBBAP has emerged as a new physiological CSP modality and has shown a stable and lower capture threshold and achieved a similarly paced QRS duration compared to HBP. It has also demonstrated stable early outcomes for feasibility and safety with a high success rate. Furthermore, the application of LBBAP has recently been extended to a resynchronization strategy. The LBBAP with SDL requires different handling and lead preparation owing to differences in lead and helix designs. Reported procedure-related acute complications of LBBAP include septal per‑ foration during the procedure, pneumothorax, pocket infection, pocket hematoma, and lead dislodgements occur‑ ring during follow-up. @*Conclusion@#LBBAP with conventional SDL has similar implant success rates, procedural safety, and pacing character‑ istics as LBBAP with LLL. However, LBBAP with SDL requires different handling and lead preparation from that of LLL owing to the differences in the lead and helix designs.
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Background@#Cardiac resynchronization therapy (CRT) is an effective treatment option for patients with heart failure (HF) and left ventricular (LV) dyssynchrony. However, the problem of some patients not responding to CRT remains unresolved. This study aimed to propose a novel in silico method for CRT simulation. @*Methods@#Three-dimensional heart geometry was constructed from computed tomography images. The finite ele‑ ment method was used to elucidate the electric wave propagation in the heart. The electric excitation and mechani‑ cal contraction were coupled with vascular hemodynamics by the lumped parameter model. The model parameters for three-dimensional (3D) heart and vascular mechanics were estimated by matching computed variables with measured physiological parameters. CRT effects were simulated in a patient with HF and left bundle branch block (LBBB). LV end-diastolic (LVEDV) and end-systolic volumes (LVESV), LV ejection fraction (LVEF), and CRT responsiveness measured from the in silico simulation model were compared with those from clinical observation. A CRT responder was defined as absolute increase in LVEF ≥ 5% or relative increase in LVEF ≥ 15%. @*Results@#A 68-year-old female with nonischemic HF and LBBB was retrospectively included. The in silico CRT simu‑ lation modeling revealed that changes in LVEDV, LVESV, and LVEF by CRT were from 174 to 173 mL, 116 to 104 mL, and 33 to 40%, respectively. Absolute and relative ΔLVEF were 7% and 18%, respectively, signifying a CRT responder.In clinical observation, echocardiography showed that changes in LVEDV, LVESV, and LVEF by CRT were from 162 to 119 mL, 114 to 69 mL, and 29 to 42%, respectively. Absolute and relative ΔLVESV were 13% and 31%, respectively, also signifying a CRT responder. CRT responsiveness from the in silico CRT simulation model was concordant with that in the clinical observation. @*Conclusion@#This in silico CRT simulation method is a feasible technique to screen for CRT non-responders in patients with HF and LBBB.
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Optimized management of atrial fibrillation requires patient-oriented decision making with a multidisciplinary approach. This report incorporates recent authoritative studies to provide detailed recommendations for managing atrial fibrillation in specific clinical settings. The principles of the Atrial fibrillation Better Care (ABC) pathway apply in these clinical settings. In addition, specific considerations are discussed for each of these conditions and populations.
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Background and Objectives@#Atrial high-rate episodes (AHREs) can be continuously detected by cardiovascular implantable electronic devices (CIEDs); however, the predictors of clinically relevant AHREs are unclear. @*Methods@#This prospective multicenter study monitored 816 patients (median age 73 years, 40.4% male) without atrial fibrillation (AF) from September 2017 to July 2020. AHREs was defined as a programmed atrial detection rate >220 beats/min. The reference values of 6 minutes and 6 hours were set to analyze clinical implication of AHREs based on previously published data that the 6 minutes excluded most episodes of oversensing. @*Results@#During a median follow-up of 18 months (interquartile interval 9–26 months), AHREs with the longest durations of >15 seconds, >6 minutes, and >6 hours and clinically documented AF by electrocardiography were noted in 246 (30.1%), 112 (13.7%), 49 (6.0%), and 24 (2.9%) patients, respectively. Among patients developing AHREs >6 minutes, 102 (91.1%) of 112 patients were identified at the 6-month visit. Patients with AHREs >6 minutes had higher proportions of sick sinus syndrome, subjects with atrial premature beat >1% on Holter monitoring, and larger left atrium (LA) size than patients with AHREs ≤6 minutes.Multivariable logistic regression analysis showed that LA diameter >41 mm (odds ratio [OR], 2.08; 95% confidence interval [95% CI], 1.25–3.45), and sick sinus syndrome (OR, 3.22; 95% CI, 1.91–5.43) were associated with AHREs >6 minutes. @*Conclusions@#In patients with LA diameter >41 mm, and sick sinus syndrome before CIEDs implantation is associated with risk of developing AHREs >6 minutes.
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Background@#We aimed to investigate the comparative risk of fracture among patients with atrial fibrillation (AF) treated with warfarin or non-vitamin K antagonist oral anticoagulants (NOACs). @*Methods@#Using the Korean National Health Insurance Service database, patients with AF who received a prescrip‑ tion for apixaban, dabigatran, rivaroxaban, or warfarin between 2013 and 2016 were included. Risk of major fractures (osteoporotic hip, vertebral, or pelvic fractures) were compared using inverse probability of treatment weighting. @*Results@#There were 70,481 patients identified (41.3% women; mean [SD] age 70.5 [11.3] years); 16,992 apixaban, 22,514 dabigatran, 27,998 rivaroxaban, and 29,390 warfarin users. During a median follow-up of 390 days, 2412 major fractures occurred with weighted incidences per 100 patient-years of 2.56 for apixaban, 2.39 for dabigatran, 2.78 for rivaroxaban, and 3.43 for warfarin. NOAC use was associated with a lower risk for fracture than warfarin use: HR 0.70 (95% confidence interval [CI] 0.57–0.86) for apixaban, HR 0.69 (95% CI 0.60–0.78) for dabigatran, and HR 0.79 (95% CI 0.70–0.90) for rivaroxaban. In head-to-head comparisons between NOACs, there was no significant difference between apixaban and dabigatran. Rivaroxaban was associated with a higher risk for fracture than dabigatran (HR 1.15, 95% CI 1.02–1.31). @*Conclusion@#In patients with AF, NOAC use may result in a lower risk for osteoporotic fracture compared with warfa‑ rin use. Fracture risk does not seem to be altered by the choice of NOAC type, except for rivaroxaban. These associa‑ tions may help inform benefit–risk assessments when choosing between the different anticoagulant types.
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Background@#We aimed to investigate the comparative risk of fracture among patients with atrial fibrillation (AF) treated with warfarin or non-vitamin K antagonist oral anticoagulants (NOACs). @*Methods@#Using the Korean National Health Insurance Service database, patients with AF who received a prescrip‑ tion for apixaban, dabigatran, rivaroxaban, or warfarin between 2013 and 2016 were included. Risk of major fractures (osteoporotic hip, vertebral, or pelvic fractures) were compared using inverse probability of treatment weighting. @*Results@#There were 70,481 patients identified (41.3% women; mean [SD] age 70.5 [11.3] years); 16,992 apixaban, 22,514 dabigatran, 27,998 rivaroxaban, and 29,390 warfarin users. During a median follow-up of 390 days, 2412 major fractures occurred with weighted incidences per 100 patient-years of 2.56 for apixaban, 2.39 for dabigatran, 2.78 for rivaroxaban, and 3.43 for warfarin. NOAC use was associated with a lower risk for fracture than warfarin use: HR 0.70 (95% confidence interval [CI] 0.57–0.86) for apixaban, HR 0.69 (95% CI 0.60–0.78) for dabigatran, and HR 0.79 (95% CI 0.70–0.90) for rivaroxaban. In head-to-head comparisons between NOACs, there was no significant difference between apixaban and dabigatran. Rivaroxaban was associated with a higher risk for fracture than dabigatran (HR 1.15, 95% CI 1.02–1.31). @*Conclusion@#In patients with AF, NOAC use may result in a lower risk for osteoporotic fracture compared with warfa‑ rin use. Fracture risk does not seem to be altered by the choice of NOAC type, except for rivaroxaban. These associa‑ tions may help inform benefit–risk assessments when choosing between the different anticoagulant types.
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Purpose@#Cardiovascular health (CVH) status is associated with several cardiovascular outcomes; however, correlations between changes in CVH status and risk of sudden cardiac death (SCD) are unknown. We aimed to evaluate associations between changes in CVH status and risk of SCD and all-cause death in older adults. @*Materials and Methods@#We used data from the Korea National Health Insurance Service-Senior cohort database (2005–2012). Six metrics from the American Heart Association (smoking, body mass index, physical activity, blood pressure, total cholesterol, and fasting blood glucose) were used to calculate CVH scores. Changes in CVH status between two health checkups were categorized as low to low, low to high, high to low, and high to high. @*Results@#We included 105200 patients whose CVH status for an initial and follow-up health checkup (2-year interval) was available. During a median of 5.2 years of follow-up after a second health checkup, 688 SCDs occurred. Compared to patients with a persistent low CVH status, those with a consistently high CVH status had a reduced risk of SCD [adjusted hazard ratio (HR), 0.69; 95% confidence interval (CI), 0.56–0.86] and all-cause death (adjusted HR, 0.74; 95% CI, 0.69–0.78). The risk of all-cause death followed similar trends. However, an inconsistent linear relationship was observed for changes in CVH status and the risk of SCD, but not of all-cause death. @*Conclusion@#Maintaining a high CVH status was associated with future risks of SCD and all-cause death among an older adult population.
ABSTRACT
Optimized management of atrial fibrillation requires patient-oriented decision making with a multidisciplinary approach. This report incorporates recent authoritative studies to provide detailed recommendations for managing atrial fibrillation in specific clinical settings. The principles of the Atrial fibrillation Better Care (ABC) pathway apply in these clinical settings. In addition, specific considerations are discussed for each of these conditions and populations.
ABSTRACT
Background and Objectives@#Atrial high-rate episodes (AHREs) can be continuously detected by cardiovascular implantable electronic devices (CIEDs); however, the predictors of clinically relevant AHREs are unclear. @*Methods@#This prospective multicenter study monitored 816 patients (median age 73 years, 40.4% male) without atrial fibrillation (AF) from September 2017 to July 2020. AHREs was defined as a programmed atrial detection rate >220 beats/min. The reference values of 6 minutes and 6 hours were set to analyze clinical implication of AHREs based on previously published data that the 6 minutes excluded most episodes of oversensing. @*Results@#During a median follow-up of 18 months (interquartile interval 9–26 months), AHREs with the longest durations of >15 seconds, >6 minutes, and >6 hours and clinically documented AF by electrocardiography were noted in 246 (30.1%), 112 (13.7%), 49 (6.0%), and 24 (2.9%) patients, respectively. Among patients developing AHREs >6 minutes, 102 (91.1%) of 112 patients were identified at the 6-month visit. Patients with AHREs >6 minutes had higher proportions of sick sinus syndrome, subjects with atrial premature beat >1% on Holter monitoring, and larger left atrium (LA) size than patients with AHREs ≤6 minutes.Multivariable logistic regression analysis showed that LA diameter >41 mm (odds ratio [OR], 2.08; 95% confidence interval [95% CI], 1.25–3.45), and sick sinus syndrome (OR, 3.22; 95% CI, 1.91–5.43) were associated with AHREs >6 minutes. @*Conclusions@#In patients with LA diameter >41 mm, and sick sinus syndrome before CIEDs implantation is associated with risk of developing AHREs >6 minutes.
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Background@#Although myocardial thickness is an important variable for therapeutic catheter ablation of cardiac arrhythmias, quantification of wall thickness has been overlooked. We developed a software (AMBER) that measures 3D-myocardial thickness using a cardiac computed tomogram (CT) image, verified its accuracy, and tested its clinical feasibility. @*Methods@#We generated 3D-thickness maps by calculating wall thickness (WT) from the CT images of 120 patients’ hearts and a 3D-phantom model (PhM). The initial vector field of the Laplace equation was oriented to calculate WT with the field lines derived from the 3D mesh. We demonstrate the robustness of the Laplace WT algorithm by comparing with the real thickness of 3D-PhM, echocardiographically measured left ventricular (LV) WT, and regional left atrial (LA) WT reported from previous studies. We conducted a pilot case of catheter ablation for atrial fibrillation (AF) utilizing real-time LAWT map-guided radiofrequency (RF) energy titration. @*Results@#AMBER 3D-WT had excellent correlations with the real thickness of the PhM (R = 0.968, p < 0.001) and echocardiographically measured LVWT in 10 patients (R = 0.656, p = 0.007). AMBER 3D-LAWT (n = 120) showed a relatively good match with 12 previously reported regional LAWT. We successfully conducted pilot AF ablation utilizing AMBER 3D-LAWT map-guided real-time RF energy titration. @*Conclusion@#We developed and verified an AMBER 3D-cardiac thickness map measured by cardiac CT images for LAWT and LVWT, and tested its feasibility for RF energy titration during clinical catheter ablation.
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Background and objectives@#A prolonged QTc interval is associated with an increased risk of a stroke or atrial fibrillation (AF). However, its direct causal relationship with AF associated a stroke has not been proven yet. To examine whether QTc interval is causally linked with risk of stroke in AF patients, we used the Mendelian randomization analysis. @*Subjects and methods@#Among 2742 patients (73.6% male; 58.2 ± 11.0 years old; 69.5% with paroxysmal AF) who underwent AF catheter ablation, we analyzed 1766 patients who had preablation sinus rhythm electrocardiograms off antiarrhythmic drugs after excluding amiodarone users. Among them, 1213 subjects had genome-wide association study dataset analyzable for the Mendelian randomization. We explored the mechanistic relationships between QTc interval (ms) and the risk of a stroke by analyzing the Mendelian randomization (1213 subjects) after reviewing 35 genetic polymorphisms associated with the QTc in 31 European descent studies. @*Results@#Among the patients in the higher quartile with a higher QTc, CHA2DS2-VASc score (p < 0.001), and age (p < 0.001), the proportions of a prior stroke (p < 0.001), females, heart failure, and persistent AF were significantly higher than in those in the lower quartile. The QTc was independently associated with the CHA2DS2-VASc score (β, 4.63E−5; 95% confidence interval, 3.57E−6–8.90E−5; p = 0.034) and ischemic strokes (odds ratio, 1.01; 95% confidence interval, 1.00–1.01; p = 0.027). However, there was no direct causal relationship between the QTc and CHA2DS2-VASc score or a prior stroke in either the one-sample or two-sample Mendelian randomizations. @*Conclusion@#The QTc was independently associated with the CHA2DS2-VASc score and strokes among the patients with AF who underwent catheter ablation, despite no genetically direct causal relationship.
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Purpose@#Implantable cardioverter defibrillators (ICD) are the standard of care for primary prevention (PP) in patients with ischemic cardiomyopathy (ICM). However, PP ICD implantation is underused in Asian countries. This study investigated ICD implantation rates and factors associated with appropriate PP ICD implants for ICM. @*Materials and Methods@#In this prospective multicenter observational registry (ADVANCE-ICM registry), ICM patients who were eligible for PP ICD were screened and enrolled. Factors associated with appropriate ICD implantation, including hospital and clinical factors, were investigated. @*Results@#Of the 1453 ICM patients eligible for PP ICD [1111 male; median age, 71.0 (61.0–78.0) years], only 76 (5.2%) patients underwent ICD implantation. Among hospital factors, a non-monetary incentive for referral (72.4% vs. 52.9%, p=0.001) and total hospital system score (6.0 vs. 5.0, p=0.013) were higher in the ICD than in the no-ICD group. In multivariate analysis, total hospital system score [odds ratio (OR), 1.28; 95% confidence interval (CI), 1.10–1.50] was an independent factor for predicting ICD implantation, along with clinical factors, including high New York Heart Association class (≥III: OR, 7.29; 95% CI, 2.97–17.87) and younger age (<70 years: OR, 2.14; 95% CI, 1.30–3.53). @*Conclusion@#PP ICD implantation for ICM patients is underused in Korea. Hospital factors were important for improving PP ICD implantation rate, suggesting that new screening and referral systems for ICM patients would improve the PP ICD implantation rate (Clinical trial registration No. NCT03590925).
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BACKGROUND AND OBJECTIVES@#Nationwide social inequalities of oral anticoagulation (OAC) usage after the introduction of non-vitamin K antagonist oral anticoagulants (NOACs) have not been well identified in patients with atrial fibrillation (AF). This study assessed overall rate and social inequalities of OAC usage after the introduction of NOAC in Korea.@*METHODS@#Between January 2002 and December 2016, we identified 888,540 patients with AF in the Korea National Health Insurance system database. The change of OAC rate in different medical systems after the introduction of NOAC were evaluated.@*RESULTS@#In all population, overall OAC use increased from 13.2% to 23.4% (p for trend <0.001), and NOAC use increased from 0% to 14.6% (p for trend <0.001). Compared with pre-reimbursement (0.48%), the annual increase of OAC use was significantly higher after partial (1.16%, p<0.001), and full reimbursement of OAC (3.72%, p<0.001). Full reimbursement of NOAC (adjusted odds ratio, 2.10; 95% confidence interval, 2.04–2.15) was independently associated with higher OAC use. However, the difference of overall OAC usage between tertiary referral hospitals and nursing or public health centers increased from 17.9% in 2010 to 36.8% in 2016. Moreover, usage rate of NOAC was significantly different among different medical systems from 37.2% at the tertiary referral hospital and 5.5% at nursing or public health centers.@*CONCLUSIONS@#Introduction of NOACs in routine practice for stroke prevention in AF was associated with improved rates of overall OAC use. However, significant practice-level variations in OAC and NOAC use remain producing social inequalities of OAC despite full reimbursement.
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Background and Objectives@#Little is known about the outcomes of outpatient clinic-based elective external cardioversion (OPC-ECV) for persistent atrial fibrillation (PeAF). We investigated the acute, short-term, and long-term elective external cardioversion (ECV) outcomes. @*Methods@#We included 1,718 patients who underwent OPC-ECV (74% male, 61.1±11.0 years old, 90.9% long-standing PeAF, 9.1% after atrial fibrillation [AF] ablation) after excluding patients with atrial tachycardia or inappropriate antiarrhythmic drug medication, and in-patient ECV. Biphasic shocks were delivered sequentially until successful cardioversion was achieved (70-100-150-200-250 J). If ECV failed at 150 J, we administered intravenous amiodarone 150 mg and delivered 200 J. @*Results@#ECV failed in 11.4%, and the complication rate was 0.47%. Within 3 months, AF recurred in 55.5% (44.7% as sustaining AF, 10.8% as paroxysmal AF), and the AF duration was independently associated (odds ratio [OR], 1.01 [1.00–1.02]; p=0.006), but amiodarone was independently protective (OR, 0.46 [0.27–0.76]; p=0.002, Log rank p<0.001) against an early recurrence. Regarding the long-term recurrence, pre-ECV heart failure was protective against an AF recurrence (hazard ratio, 0.63 [0.41–0.96], p=0.033) over 32 (9–66) months of follow-up. ECV energy (p<0.001) and early recurrence rate within 3 months (p=0.007, Log rank p=0.006) were significantly lower in post-ablation patients than in those with long-standing persistent AF. @*Conclusions@#The success rate of OPC-ECV was 88.6%, and the complication rate was low. However, AF recurred in 55.5% within 3 months. Amiodarone was protective against short-term AF recurrences, and long-term AF recurrences were less in patients with baseline heart failure.
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BACKGROUND AND OBJECTIVES@#The objective of this study was to evaluate the long-term clinical outcomes and the incidence of permanent pacemaker implantation after catheter ablation in patients with of atrial fibrillation (AF) and sinus node dysfunction (SND).@*METHODS@#Among 3,068 total consecutive patients who underwent AF catheter ablation (AFCA), this study included 222 (9.5%; men 53.2%, 63.7±9.2 years of age, 81.5% paroxysmal AF) with underlying SND and a regular rhythm follow-up. We analyzed the rhythm outcomes, changes in the mean heart rate or heart rate variability, and permanent pacemaker implantation rate.@*RESULTS@#During 47.5±28.8 months of follow-up, 25 (11.3%) patients received pacemaker implantations due to symptomatic SND. More than half (56.0%, 14/25) underwent a pacemaker implantation within 3 months of the AFCA, and the annual pacemaker implantation rate was 2.0% afterwards. Both the early (68.0% vs. 31.0%, p<0.001) and clinical AF recurrence (68.0% vs. 32.5%, p=0.001) rates and continuous antiarrhythmic drug use after 3 months (44.0% vs. 24.4%, p=0.036) were significantly higher in patients requiring pacemaker implantations than those that did not. An anterior linear ablation (odds ratio [OR], 9.37 [3.03–28.9]; p<0.001) and the E/Em (OR, 1.15 [1.02–1.28]; p=0.018) were independently associated with permanent pacemaker implantations after AFCA in patients with AF and SND.@*CONCLUSIONS@#After AFCA in patients with AF and SND, 1 of 9 patients needed a pacemaker implantation and half needed implantations within 3 months. The AF recurrence rate was significantly higher in those who required pacemaker implantations after the AFCA.
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Background/Aims@#The current study aimed to elucidate a time-course change in left atrial volume after cardiac resynchronization therapy (CRT) and to verify factors associated with left atrial volume reduction (LAVR) and its prognostic implications. @*Methods@#The records of 97 patients were retrospectively reviewed after CRT.Echocardiographic data were analyzed at baseline before CRT, at early follow-up FU) (≤ 1 year, median 6 months), and at late FU (median 30 months). Left ventricular volume response (LVVR) was defined as 15% reduction in left ventricular (LV) end-systolic volume (ESV). LAVR was classified into two groups by the median value at early FU: LAVR (≥ 7.5%) and no LAVR (< 7.5%). @*Results@#LV ESV index continuously decreased from baseline to early FU and from early FU to late FU (106.1 ± 47.4 mL/m2 vs. 87.6 ± 51.6 mL/m2 vs. 72.5 ± 57.1 mL/m2).LA volume index decreased from baseline to early FU, but there were no reductions thereafter (51.8 ± 21.9 mL/m2 vs. 45.1 ± 19.6 mL/m2 vs. 44.9 ± 23.0 mL/m2).The only echocardiographic factor associated with LAVR was change in E velocity(odds ratio [OR], 1.04;p = 0.002). Early LAVR (OR, 10.05;p = 0.002) was an independent predictor for late LVVR. @*Conclusions@#LAVR was related to reduction in E velocity, suggesting its relation with optimization of LV filling pressure. Early LAVR was a predictor for LVVR to CRT in long-term FU.