Joint Mexican position document on the treatment of atrial fibrillation / Posicionamiento conjunto acerca del tratamiento para fibrilación auricular

Abstract Atrial fibrillation (AF) is a frequent arrhythmia; its prevalence is near 2% in the general population; in Mexico, more than one-half million people are affected. AF needs to be considered as a public health problem. Because AF is an independent risk factor associated with mortality, due to embolic events, heart failure, or sudden death; early diagnosis is of utmost importance. In unstable patients with a recent onset of AF, electrical cardioversion should be practiced. In stable patients, once thromboembolic measures have been taken, it is necessary to assess whether it is reasonable to administer an antiarrhythmic drug to restore sinus rhythm or performed electrical cardioversion. For recidivating cases of paroxysmal and persistent presentation, the most effective strategy is performed pulmonary vein isolation with either radiofrequency or cryoballoon energy. Permanent AF is that in which recovery of sinus rhythm is not possible, the distinguishing feature of this phase is the uncontrollable variability of the ventricular frequency and could be treated pharmacologically with atrioventricular (AV) nodal blockers or with a VVIR pacemaker plus AV nodal ablation. The presence of AF has long been associated with the development of cerebral and systemic (pulmonary, limb, coronary, renal, and visceral) embolism. The prevention of embolisms in “valvular” AF should perform with Vitamin K antagonists (VKA). For patients with AF not associated with mitral stenosis or a mechanical valve prosthesis, a choice can be made between anticoagulant drugs, VKA, or direct oral anticoagulants. Antiplatelet agents have the weakest effect in preventing embolism.

Resumen La fibrilación auricular (FA) es una arritmia frecuente; su prevalencia es cercana al 2% en la población general, en México se ven afectados más de medio millón de personas por eso debe considerarse como un problema de salud pública. Debido a que la FA es un factor de riesgo independiente asociado a mortalidad, por eventos embólicos, insuficiencia cardíaca o muerte súbita, la identificación y diagnóstico temprano es de suma importancia. En el inicio reciente de FA en pacientes inestables, se debe practicar la cardioversión eléctrica. En pacientes estables, una vez que se han tomado medidas tromboembólicas, es necesario evaluar si es razonable administrar un medicamento antiarrítmico para restaurar el ritmo sinusal o realizar una cardioversión eléctrica. Para los casos que recidivan, ya sea paroxística o persistente, la estrategia más efectiva es realizar el aislamiento de la venas pulmonares con radiofrecuencia o crioablación con balón. La FA permanente es aquella en la que no es posible la recuperación del ritmo sinusal, la característica distintiva de esta fase de la FA es la variabilidad incontrolable de la frecuencia ventricular. Puede tratarse farmacológicamente con bloqueadores nodales AV o con un marcapasos VVIR mas ablación del nodo AV. La presencia de FA se ha asociado durante mucho tiempo con el desarrollo de embolia cerebral y sistémica (pulmonar, de extremidades, coronaria, renal y visceral). La prevención de embolias en la FA “valvular” debe realizarse con antagonistas de la vitamina K (AVK). Para los pacientes con FA no asociados con estenosis mitral o una prótesis valvular mecánica, se puede elegir entre medicamentos anticoagulantes, AVK o anticoagulantes orales directos (DOAC). Los agentes antiplaquetarios tienen el efecto más débil para prevenir la embolia.

Thawing rate predicts acute pulmonary vein isolation after second-generation cryoballoon ablation

OBJECTIVE: To evaluate whether thawing rate could be a novel predictor of acute pulmonary vein isolation (PVI) and explore the predictive value of thawing rate as a factor ensuring long-term PVI (vagus reflex). METHODS: A total of 151 patients who underwent cryoballoon ablation for atrial fibrillation (AF) were enrolled in this retrospective study between January 2017 and June 2018. The thawing rate was calculated using the thawing phase of the cryoablation curve. Receiver operating characteristic (ROC) curve was used to analyze the predictive value of the thawing rate for acute PVI and vagus reflex. RESULTS: ROC curve analyses revealed that the interval thawing rate at 15°C (ITR15) was the most valuable predictor of PVI, with the highest area under curve (AUC) value of the ROC curve. The best cut-off value of ITR15 for PVI was ≤2.14°C/S and its sensitivity and specificity were 88.62% and 67.18%, respectively. In addition, the ITR15 of the successful PVI group after cryoballoon ablation was significantly slower than the failed PVI group. ITR15 was a predictor of vagus reflex and the occurrence of vagus reflex group had a slower ITR15 compared to the non-occurrence group. CONCLUSIONS: Thawing rate was a novel predictor of acute PVI and the ITR15 was the most valuable predictor of acute PVI. In addition, ITR15 was a predictive factor ensuring long-term PVI (vagus reflex). Our study showed that thawing rate may serve in the early identification of useless cryoballoon ablation.

The Thickness of Epicardial Adipose Tissue Adjacent to the Right Coronary Artery Predicts Recurrence of Atrial Fibrillation After Cryoballoon Ablation: A Simpler Method / El grosor del tejido adiposo epicárdico adyacente a la arteria coronaria derecha predice la recurrencia de la fibrilación auricular después de la crioablación con balón: Un método más sencillo

ABSTRACT Objective: Epicardial adipose tissue (EAT) is a metabolically active tissue and increased thickness is correlated with various cardiovascular diseases. There are various ways to estimate EAT. In this study, we investigated the predictive value of EAT thickness adjacent to the right coronary artery (RCA) for late atrial fibrillation (AF) recurrences in patients treated with cryoballoon ablation (CBA). We propose that this method is simpler than other methods for measurement of EAT on multidetector computed tomography images. Methods: Patients with symptomatic paroxysmal or persistent AF despite one or more anti-arrhythmic drugs who were scheduled for CBA were prospectively recruited. Multidetector computed tomography was performed and epicardial adipose tissue thickness was measured as the fat-thickness from the epicardium to the myocardium around the RCA just after the acute marginal branch. The duration of follow-up was 12 months and AF recurrence was defined as an episode of AF longer than 30 seconds duration occurring three months after CBA. The study population included 72 patients and in 22 patients (30.5%) AF recurrence was observed. Results: Epicardial adipose tissue thickness was significantly higher in patients who had late recurrent AF compared to the patients without late recurrence (12.3 ± 3.2 vs 10.2 ± 3.2, p < 0.01). Highly sensitive C-reactive protein (Hs-CRP) level and left atrial (LA) volume index were significantly higher in the recurrent AF group compared to patients without AF recurrence. Multivariable analysis showed that LA volume index (OR 1.41, 95 % CI:1.15, 1.73, p < 0.01), hs-CRP (OR 1.42, 95% CI:1.02, 1.94, p = 0.04) and EAT thickness (OR 1.34, 95% CI:1.05, 1.71, p = 0.02) remained as independent predictors of AF recurrence in the study population. Conclusion: Epicardial adipose tissue thickness adjacent to the RCA is associated with late AF recurrences in patients treated with CBA. This method of EAT quantification seems to be simpler, less time-consuming and may be an alternative to other methods of EAT measurement.

RESUMEN Objetivo: El tejido adiposo epicárdico (TAE) es un tejido metabólicamente activo y el aumento del grosor se correlaciona con varias enfermedades cardiovasculares. Hay varias maneras de estimar el TAE. En este estudio, investigamos el valor predictivo del grosor del TAE adyacente a la arteria coronaria derecha (ACD) para las recurrencias tardías de la fibrilación auricular (FA) en pacientes tratados con crioablación con balón (CAB). Proponemos que este método es más simple que otros métodos para la medición del TAE en las imágenes de la tomografía computarizada con detectores múltiples. Método: Pacientes con FA paroxística sintomática o persistente - a pesar de uno o más fármacos antiarrítmicos - que estaban programados para CAB, fueron reclutados prospectivamente. Se realizó la tomografía computarizada con detectores múltiples y el grosor del tejido adiposo epicárdico del tejido fue medido como el grosor de la grasa desde el epicardio al miocardio alrededor de la ACD, justamente tras la rama marginal aguda. La duración del seguimiento fue de 12 meses y la recurrencia de FA se definió como un episodio de FA de más de 30 segundos de duración ocurrido tres meses después de la CAB. La población de estudio incluyó 72 pacientes, y en 22 pacientes (30.5%) se observó recurrencia de FA. Resultados: El grosor del tejido adiposo epicárdico fue significativamente mayor en pacientes con FA de recurrencia tardía, en comparación con los pacientes sin recurrencia tardía (12.3 ± 3.2 vs 10.2 ± 3.2, p < 0.01). El nivel de la proteína C reactiva altamente sensible (PCR-as) y el índice del volumen auricular izquierdo (AI) fueron perceptiblemente más altos en el grupo de FA recurrente en comparación con los pacientes sin FA recurrente. El análisis multivariable mostró que el índice de volumen AI (OR 1.41, 95% IC: 1.15, 1.73, p < 0.01), PCR-as (OR 1.42, 95% IC: 1.02, 1.94, p = 0.04) y el grosor del TAE (OR 1.34, 95% IC: 1.05, 1.71, p = 0.02) permanecieron como predictores independientes de la recurrencia de FA en la población de estudio. Conclusión: El grosor del tejido adiposo epicárdico adyacente a la ACD se halla asociado con las recurrencias tardías de FA en pacientes tratados con CAB. Este método de cuantificación de TAE parece ser más simple, consume menos tiempo, y puede ser una alternativa a otros métodos de medición de TAE.

Impact of Pulmonary Vein Anatomy on Long-term Outcome of Cryoballoon Ablation for Atrial Fibrillation / 华中科技大学学报（医学）（英德文版）

Variant pulmonary vein anatomy (PVA) has been reported to influence the recurrence of atrial fibrillation (AF) after radiofrequency ablation.However,the effects of PVA on AF in patients undergoing cryoballoon ablation (CBA) remain unknown.The present study aimed to examine the impact of PVA on the long-term outcome of CBA for AF.A total of 78 patients (mean age 60.7±10.9 years,64.1％ males) with symptomatic and drug-refractory paroxysmal AF were enrolled in the study.Left atrium (LA) and PVA acquired at computed tomography angiography (CTA) were reconstructed with CARTO(R) 3 SYSTEM.Patients were routinely evaluated by 24-hour Holter monitoring following CBA.Cox regression was used to detect the predictors of AF recurrence after CBA.The results showed abnormal PVA in 30 patients (38.5％) and 18 patients (23.1％) had left common PV (LCPV).Electrical pulmonary vein isolation was achieved in all patients.After a mean follow-up of 689.5±103.8 days,it was found that patients with abnormal PVA had similar AF recurrence rate to those with normal PVA (26.7％ vs.25.0％,P=0.54),and there was no significant difference in AF recurrence rate between LCPV patients and non-LCPV patients (33.7％ vs.23.3％,P=0.29).Cox regression analysis showed that AF duration (72.9±9.0 vs.42.3±43.2 months,HR 1.001;95％CI 1.003-1.014;P＜0.001) and cryo-applications of right-side PVs (3.0±1.6 vs.4.7±1.7,HR 0.661;95％ CI 0.473-0.925;P=0.016) were independent predictors of freedom from AF,but PVA was not identified as a predictor of long-term success.In conclusion,the variant PVA cannot significantly influence the long-term outcome of AF patients undergoing CBA;longer AF duration and less cryo-applications of right-side PVs are associated with higher AF recurrent rate.

Impact of Pulmonary Vein Anatomy on Long-term Outcome of Cryoballoon Ablation for Atrial Fibrillation / 华中科技大学学报（医学）（英德文版）

Variant pulmonary vein anatomy (PVA) has been reported to influence the recurrence of atrial fibrillation (AF) after radiofrequency ablation.However,the effects of PVA on AF in patients undergoing cryoballoon ablation (CBA) remain unknown.The present study aimed to examine the impact of PVA on the long-term outcome of CBA for AF.A total of 78 patients (mean age 60.7±10.9 years,64.1％ males) with symptomatic and drug-refractory paroxysmal AF were enrolled in the study.Left atrium (LA) and PVA acquired at computed tomography angiography (CTA) were reconstructed with CARTO(R) 3 SYSTEM.Patients were routinely evaluated by 24-hour Holter monitoring following CBA.Cox regression was used to detect the predictors of AF recurrence after CBA.The results showed abnormal PVA in 30 patients (38.5％) and 18 patients (23.1％) had left common PV (LCPV).Electrical pulmonary vein isolation was achieved in all patients.After a mean follow-up of 689.5±103.8 days,it was found that patients with abnormal PVA had similar AF recurrence rate to those with normal PVA (26.7％ vs.25.0％,P=0.54),and there was no significant difference in AF recurrence rate between LCPV patients and non-LCPV patients (33.7％ vs.23.3％,P=0.29).Cox regression analysis showed that AF duration (72.9±9.0 vs.42.3±43.2 months,HR 1.001;95％CI 1.003-1.014;P＜0.001) and cryo-applications of right-side PVs (3.0±1.6 vs.4.7±1.7,HR 0.661;95％ CI 0.473-0.925;P=0.016) were independent predictors of freedom from AF,but PVA was not identified as a predictor of long-term success.In conclusion,the variant PVA cannot significantly influence the long-term outcome of AF patients undergoing CBA;longer AF duration and less cryo-applications of right-side PVs are associated with higher AF recurrent rate.

Risk factors of recurrence of atrial fibrillation in aged patients with chronic diseases after cryoballoon ablation / 上海交通大学学报（医学版）

Objective • To evaluate the recurrence rate of atrial fibrillation (Af) and its related risk factors in aged patients with chronic diseases after cryoballoon ablation. Methods • With the method of convenient sampling, a total of 159 patients with Af after cryoballoon ablation were enrolled in the Department of Cardiology, Ruijin Hospital from Oct. 2016 to Jan. 2018. Self-rating depression scale (SDS) and CHA2DS2-VASc scores [congestive heart failure, hypertension, age ≥ 75 y (doubled), diabetes mellitus, stroke(doubled)-vascular disease, age 65-74 and sex category(female)] were used to assess the patients. Follow-up checks consisted of chief complaint, postoperative electrocardiogram (ECG), and 24 h Holter monitoring. Logistic regression models were performed to explore the independent risk factors of Af recurrence after cryoballoon ablation. Results • 152 patients (95.6%) completed the follow-up checks, with an average age of (61.9±8.9) years. The average time of follow-up period was (8.35±2.41) months. A total of 41 patients (27.0%) developed Af after cryoballoon ablation. Logistic regression analysis showed the number of chronic disease ≥ 2 (OR=2.466, 95% CI: 1.375-4.452), CHA2DS2-VASc scores ≥ 2 (OR=2.088, 95% CI: 1.142-5.557), irregular use of anti-arrhythmic drugs (OR=1.581, 95% CI: 1.351-2.125), hypertension (OR=1.317, 95% CI: 1.076-2.809), and body mass index (BMI) (OR=1.147, 95% CI: 1.009-1.174) were the independent risk factors of Af recurrence. Conclusion • There is still a certain percentage of recurrence in aged patients with chronic diseases after cryoballoon ablation. 2 and more chronic diseases, irregular use of anti-arrhythmic drugs, hypertension, CHA2DS2-VASc scores ≥ 2, and overweight may be potential risk factors of Af recurrence after cryoballoon ablation.

Cryoballoon ablation versus radiofrequency ablation for paroxysmal atrial fibrillation: a meta-analysis of curative effect / 介入放射学杂志

Objective To comprehensively evaluate the clinical effect of cryoballoon ablation (CBA) and radiofrequency ablation (RFA) in treating paroxysmal atrial fibrillation (PAF).Methods Computer retrieval of PubMed,EMbase,the Cochrane Library,Web of Knowledge,China national knowledge infrastructure (CNKI),Chinese Biomedical Medical Literature (CBM),China Wan Fang,China VIP,and other database to collect the randomized control trials (RCT) related to RFA and CBA treatment for PAF.The retrieval time was from the establishment of database to December 2015.The data extraction and methodological quality of the included studies were assessed by two reviewers independently.And meta-analysis was conducted by using RevMan 5.2 software.Results A total of 6 research papers (636 patients in total) were included.The results of meta-analysis showed that the incidence of phrenic nerve paralysis in CBA group was significantly higher than that in RFA group (RR=9.26,95％CI:2.17-39.63,P=0.003).No statistically significant differences in the operation time (MD=10.07,95％CI:-9.10-30.52,P=0.29),fluoroscopy time (MD=-0.18,95％CI:-8.14-7.77,P=0.96),12-month success rate (RR=0.91,95％CI:0.72-1.14,P=0.40) and the incidences of atrial tachycardia,atrial flutter,atrioventricular reentrant tachycardia existed between CBA group and RFA group (RR=0.47,95％CI:0.11-2.02,P=0.31).Conclusion For the treatment of PAF,no obvious differences in the operation time,fluoroscopy time,12-month success rate,and the incidences of atrial tachycardia,atrial flutter,atrioventricular reentrant tachycardia exist between CBA and conventional RFA,but CBA can increase the incidence of phrenic nerve paralysis.