Postcardiac injury syndrome caused by radiofrequency catheter ablation of persistent atrial fibrillation: severe pulmonary arterial hypertension with severe tricuspid regurgitation: a rare case report and literature review.

BACKGROUND: Postcardiac injury syndrome (PCIS) is an easy-to-miss diagnosis, but it is not an uncommon complication. The phenomenon of echocardiography (ECHO) showing both severe pulmonary arterial hypertension (PAH) and severe tricuspid regurgitation (TR) is indeed rare in PCIS after extensive radiofrequency ablation. CASE PRESENTATION: A 70-year-old male was diagnosed with persistent atrial fibrillation. The patient received radiofrequency catheter ablation due to his atrial fibrillation being refractory to antiarrhythmic drugs. After the anatomical three-dimensional models were created, ablations were performed on the left and right pulmonary veins, roof linear and bottom linear of the left atrium, and the cavo-tricuspid isthmus. The patient was discharged in sinus rhythm (SR). After 3 days, he was admitted to the hospital for gradually worsening dyspnea. Laboratory examination showed a normal leukocyte count with an increased percentage of neutrophils. The erythrocyte sedimentation rate, C-reactive protein concentration, interleukin-6, and N-terminal pro-B-type natriuretic peptide were elevated. ECG exhibited SR, V1-V4 of precordial lead P-wave amplitude which was increased but not prolonged, PR segment depression, and ST-segment elevation. Computed tomography angiography of the pulmonary artery revealed that the lung had scattered high-density flocculent flakes and a small amount of pleural and pericardial effusion. Local pericardial thickening was seen. ECHO showed severe PAH with severe TR. Diuretics and vasodilators did not relieve the symptoms. Tumors, tuberculosis, and immune system diseases were all excluded. Considering the patient's diagnosis of PCIS, the patient was treated with steroids. The patient recovered on the 19th day post ablation. The patient's condition was maintained until 2 years of follow-up. CONCLUSIONS: The phenomenon of ECHO showing severe PAH with severe TR is indeed rare in PCIS. Due to the lack of diagnostic criteria, such patients are easily misdiagnosed, leading to a poor prognosis.

Randomized controlled study protocol: Shensong Yangxin in persistent atrial fibrillation after radiofrequency catheter ablation (SS-ADJUST)

Introduction: Atrial fibrillation (AF) is one of the most common forms of arrhythmia in the clinic. There are about 10 million AF patients in China, of which 1/3 are paroxysmal AF, and the remaining 2/3 are persistent or permanent AF. Long-term AF impairs cardiac function and leads to heart failure and thromboembolism. Moreover, AF increases the risk of mortality and ischemic stroke. Drug therapy and radiofrequency catheter ablation (RFCA) are still the mainstream treatment for AF patients. However, drug therapy has its drawbacks because of the high recurrence rate and side effects. Therefore, the current antiarrhythmic drugs could not meet all the clinical needs of patients with AF. RFCA is superior to antiarrhythmic drugs in maintaining sinus rhythm, improving symptoms and exercise tolerance, and improving quality of life. The role of RFCA in the treatment of persistent AF has gradually been recognized and affirmed. Although RFCA has been progressively used in the treatment of AF, there is still a high recurrence rate of AF after RFCA, especially in patients with persistent AF. Hence, it is meant to solve the high recurrence rate of AF after RFCA. Shensong Yangxin (SSYX) capsule has been proven to treat arrhythmia both in animal studies and clinical research. SSYX capsule could regulate multi-ion channels, improve cardiomyocyte metabolism and regulate autonomic nervous function. In addition, randomized, double-blind, multicenter clinical research indicated that the SSYX capsule exhibited good clinical efficacy in treating ventricular premature beats and paroxysmal AF. However, the effect of SSYX on recurrence after RFCA for patients with persistent AF remains unclear. High-level randomized controlled trials (RCTs) could offer clinicians high-quality evidence regarding the usage of SSYX capsule, especially in persistent AF patients who received RFCA. Hence, the RCTs aim to evaluate the effect of SSYX capsules on the prognosis in patients with persistent AF after RFCA through multicenter, double-blind RCTs. Method(s): This trial will be conducted with a total of 920 participants diagnosed with persistent AF who received RFCA. The participants will be randomized (1:1) into groups receiving either SSYX or Placebo for 1 year. The primary endpoint includes the recurrence of AF within 1 year after RFCA. The secondary outcome measures include changes of AF load at 3 months, 6 months, 9 months, and 1 year after treatment, the time of first atrial flutter/AF, the incidence of cardioversion 1 year after treatment, changes of transthoracic echocardiographic parameters 1 year after treatment, the incidence of stroke and thromboembolism at 6 months and 1 year after treatment, the score of SF-36 within 1 year after treatment. Application: The trial is ongoing. The trial started in September 2019 and recruiting patients. Data collection will be completed after all participants have completed the treatment course and follow-up assessments (expected in 2022, pending COVID-19). Next Steps/Future: The SS-ADJUST study is a randomized control study of TCM in persistent AF after RFCA. It will determine the place of SSYX capsule as a new treatment approach and provide additional and innovative information regarding TCM and the specific use of SSYX in persistent AF after RFCA.

Alteration of right ventricular function after catheter ablation in patients with persistent atrial fibrillation and concomitant heart failure with preserved ejection fraction

Objective To investigate the alteration of right ventricular function after catheter ablation in patients with persistent atrial fibrillation (PAF) and concomitant heart failure with preserved ejection fraction (HFpEF). Methods The prospective observational study was performed in patients with HFpEF-PAF and undergoing first-time radiofrequency ablation procedures in the First Affiliated Hospital of Nanjing University between May to December 2019. Right ventricular functional parameters were measured before and 5 days, 1, 3, 6 and 12 months after the ablation by transthoracic echocardiography, respectively, including the right ventricular fractional area change (RVFAC). tricuspid annular plane systolic excursion(TAPSE), tricuspid annular diameter (TVAD). tricuspid annular peak systolic speed(TDI-S) and longitudinal strain of right ventricular free wall (RVFLS). Meanwhile, routine ECG and Holler recordings were performed at each follow-up time point. Results In this study, atrial fibrillation (AF) recurrence occurred in 4 patients at the 3rd month after ablation, and 7 patients failed to follow up due to the Covid-19. Finally, 19 patients were followed up for the evaluation of cardiac function after catheter ablation. Compared with pre-ablation, right ventricular structural and functional paramters (RVFAC, TAPSE, TVAD, TDI-S. RVFLS) improved significantly at all stages of follow-up(all P <0.05). Patients with atrial fibrillation recurrence had lower RVFLS and TDI-S at the baseline(P =0.039, P =0.019). Conclusions Right ventricular function could improve in HFpEF-PAF patients who maintain sinus rhythm after radiofrequency ablation. © 2022 ChinJUltrasonogr. All rights reserved.

A RANDOMIZED CLINICAL TRIAL OF SCREENING FOR ATRIAL FIBRILLATION WITH A 14-DAY PATCH MONITOR: ANALYSIS OF ECG RECORDINGS FROM THE GUARD-AF STUDY

Background: Screening for atrial fibrillation (AF) is attractive because AF can remain undiagnosed and AF-related stroke can be prevented by anticoagulants (OAC). Methods: A randomized trial of screening for AF in individuals ≥70 years old without AF. Stroke and major bleeding are the efficacy and safety outcomes, ascertained from claims databases and electronic health records. Screening is done using a Zio®XT 14-day continuous cardiac rhythm patch monitor and compared, 1:1, to usual care. Use of OAC for detected AF is decided by patients and their physicians. The planned sample size was 52,000 recruited from U.S. primary care practices. Enrollment was severely hampered by the COVID-19 pandemic and stopped May 31, 2021 with 11,931 participants. Follow-up for stroke and bleeding events continues. Here, we report patch monitor findings from the 5,965 participants randomized to the screening arm. Results: 5,720 (96%) participants returned patches with analyzable data, the largest sample of patch monitor AF screening to date. Median (IQR) age was 75 (72, 79) years;57% were women. Median wear time was 13.9 (13.7, 14.0) days and median analyzable time was 98.4% (95.6, 99.5). 255 (4.5%) participants had AF, including 30 (0.5%) with 100% AF. 100% AF was more common in those age ≥80 (1.0%) than among younger participants (0.40%), p<.01. In the 225 participants with paroxysmal AF (PAF), median AF “burden” was 0.48% (0.016-2.5) of time monitored [78 (3.2, 454) minutes]. Median number of AF episodes during monitoring was 3 (1, 19). Median longest single AF episode was 60 (3-278) minutes. AF burden and length of longest episode were highly correlated (r=0.79, p<.001). Neither of these measures of PAF were associated with either age or sex. Conclusion: In GUARD-AF’s older primary care population, 0.5% of screened participants had persistent AF and 4% had PAF detected within 2 weeks of monitoring. In those with PAF, average AF burden was low but >25% had an episode of ≥4.6 hours of continuous AF, suggesting increased stroke risk. The need for stroke-preventive interventions (e.g., OAC) for screen-detected PAF remains a critically important research question.