Impact of atrial fibrillation recurrences during the blanking period following catheter ablation on long-term arrhythmia-free survival: a prospective study with continuous monitoring.

BACKGROUND: The significance of atrial fibrillation (AF) recurrences during the 90-day blanking period following catheter ablation is controversial. Studies to date examining the impact of AF recurrences during the blanking period have been limited by intermittent monitoring. We sought to test whether AF recurrences during the blanking period are associated with long-term recurrences using continuous monitoring. METHODS: Patients undergoing AF ablation by a single operator at an academic medical center between 2015 and 2019, who either already had a cardiac implantable electronic device (CIED) with an atrial lead or received an insertable cardiac monitor (ICM), were followed for long-term AF recurrence. Recurrence was defined as > 30 s by CIED and > 2 min by ICM. All device-reported AF episodes were adjudicated by a physician. RESULTS: Of 196 consecutive patients, 51 (26%) had AF recurrence in the blanking period and 145 (74%) did not. Over the year following ablation, those who had an AF recurrence in the blanking period were significantly more likely to have long-term AF recurrences than those without AF in the blanking period (log rank p < 0.001). The higher the burden of AF recurrences during the blanking period, the more likely AF was to recur long-term (hazard ratio 1.04 [CI 1.01-1.06] per 1% increase in burden, p = 0.002). CONCLUSION: Using continuous monitoring of a sizable population, we confirmed that AF recurrences in the blanking period following ablation are in fact associated with long-term AF recurrences. The higher the burden of recurrence, the more likely AF is to recur long-term.

Effect of Transcutaneous Magnetic Stimulation in Patients With Ventricular Tachycardia Storm: A Randomized Clinical Trial.

IMPORTANCE: Autonomic neuromodulation provides therapeutic benefit in ventricular tachycardia (VT) storm. Transcutaneous magnetic stimulation (TcMS) can noninvasively and nondestructively modulate a patient's nervous system activity and may reduce VT burden in patients with VT storm. OBJECTIVE: To evaluate the safety and efficacy of TcMS of the left stellate ganglion for patients with VT storm. DESIGN, SETTING, AND PARTICIPANTS: This double-blind, sham-controlled randomized clinical trial took place at a single tertiary referral center between August 2019 and July 2021. The study included 26 adult patients with 3 or more episodes of VT in 24 hours. INTERVENTIONS: Patients were randomly assigned to receive a single session of either TcMS that targeted the left stellate ganglion (n = 14) or sham stimulation (n = 12). MAIN OUTCOMES AND MEASURES: The primary outcome was freedom from VT in the 24-hour period following randomization. Key secondary outcomes included safety of TcMS on cardiac implantable electronic devices, as well as burden of VT in the 72-hour period following randomization. RESULTS: Among 26 patients (mean [SD] age, 64 [13] years; 20 [77%] male), a mean (SD) of 12.7 (10.3) episodes of VT occurred within the 24 hours preceding randomization. Patients had recurrent VT despite taking a mean (SD) of 2.0 (0.6) antiarrhythmic drugs (AADs), and 11 patients (42%) required mechanical hemodynamic support at the time of randomization. In the 24-hour period after randomization, VT recurred in 4 of 14 patients (29% [SD 47%]) in the TcMS group vs 7 of 12 patients (58% [SD 51%]) in the sham group (P = .20). In the 72-hour period after randomization, patients in the TcMS group had a mean (SD) of 4.5 (7.2) episodes of VT vs 10.7 (13.8) in the sham group (incidence rate ratio, 0.42; P < .001). Patients in the TcMS group were taking fewer AADs 24 hours after randomization compared with baseline (mean [SD], 0.9 [0.8] vs 1.8 [0.4]; P = .001), whereas there was no difference in the number of AADs taken for the sham group (mean [SD], 2.3 [0.8] vs 1.9 [0.5]; P = .20). None of the 7 patients in the TcMS group with a cardiac implantable electronic device had clinically significant effects on device function. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, findings support the potential for TcMS to safely reduce the burden of VT in the setting of VT storm in patients with and without cardiac implantable electronic devices and inform the design of future trials to further investigate this novel treatment approach. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04043312.

Continuous rhythm monitoring-guided anticoagulation after atrial fibrillation ablation.

INTRODUCTION: Oral anticoagulation (OAC) based on estimated stroke risk is recommended following catheter ablation (CA) of atrial fibrillation (AF), regardless of the extent of arrhythmia control. However, discontinuing OAC in selected patients may be safe. We sought to evaluate a strategy of OAC discontinuation following AF ablation guided by continuous rhythm monitoring. METHODS AND RESULTS: We prospectively studied AF ablations performed at our institution from June 2015 to December 2019. Patients that had pre-existing cardiac implantable electronic devices (CIEDs) or underwent insertable cardiac monitor (ICM) implantation immediately following AF ablation were included. OAC was continued for 6 weeks following CA in all patients, following which OAC management was guided by CHA2 DS2 -VASc score and continuous rhythm monitoring results, according to a prespecified protocol. AF recurrence was defined as ≥30 s (CIEDs) or ≥2 min (ICM). We studied 196 patients (mean age 64.7 ± 11.3 years, 66.8% male, 85.7% ICM, 14.3% CIEDs). Mean CHA2 DS2- VASc score was 2.2 ± 1.5. One-year AF-free survival following CA was 83% for paroxysmal AF and 63% for persistent AF patients. Over 3 year follow-up, OAC was discontinued in 57 (33.7%) patients, mean 7.4 ± 7.1 months following ablation. Following discontinuation, OAC was restarted for AF recurrence in 9 (15.8%) patients, mean 11.7 ± 6.8 months after stopping. This discontinuation protocol led to a 21.9% reduction in overall time exposed to OAC. There were no thromboembolic or major bleeding events. CONCLUSION: OAC can be discontinued in a significant percentage of patients following CA of AF. When guided by continuous rhythm monitoring, this practice does not unacceptably increase the risk of thromboembolic events.

Improvement in tricuspid regurgitation following catheter ablation of atrial fibrillation.

INTRODUCTION: Functional tricuspid regurgitation (TR) remains a challenging clinical problem with poor outcomes and few effective treatments. Atrial fibrillation (AF) has been associated with functional TR. We sought to determine whether restoring sinus rhythm through catheter ablation of AF can decrease the degree of TR. METHODS AND RESULTS: A retrospective cohort study of patients undergoing AF ablation between 2011 and 2017 at a single center was conducted. We included patients with at least moderate TR on echocardiogram within the year preceding ablation, who underwent repeat echocardiogram within the year following ablation. Formal quantitative analysis was performed by an experienced research echocardiographer, blinded to arrhythmia outcomes. Arrhythmia-free survival was correlated to the extent of improvement in TR. Thirty-six patients met the inclusion criteria. A baseline echocardiogram was performed 37 ± 68 days before ablation and follow-up echocardiogram 139 ± 112 days following ablation. Patients were 63.7 ± 11.1 years old with a mean CHA2 DS2 -VASc score of 2.7 ± 1.7. The degree of TR improved by at least one grade in 23 patients (64%). TR area decreased from 11.6 ± 3.4 to 7.0 ± 3.5 cm2 (p < .001) following ablation. Freedom from AF postablation was associated with a greater likelihood of improvement in TR by at least one grade (100% vs. 41%, p = .02). CONCLUSIONS: In patients with AF and at least moderate TR, catheter ablation is associated with substantial improvement in TR severity.

Trends in Authorship Demographics for Manuscripts Published in The American Journal of Cardiology.

The demographics of authors in manuscript publications have been investigated in many specialties but not yet cardiology. We explored the authorship trends in The American Journal of Cardiology, a fundamental journal in this field, to uncover the historical demographic patterns in the field. Manuscripts published in 1958 (the first year of publication), 1966, 1976, 1986, 1996, 2006, and 2016 were analyzed. Parameters used were gender of first and last authors, number of authors per article, the authors' qualifications and country of corresponding authors. A total of 4,329 articles were analyzed. We hypothesized an increase in authors per article, variety of authors' degrees, countries contributing to authorship, and an increase in female authorship over time. We found that the mean number of authors per article increased from 1.8 in 1958 to 8.6 in 2016. Qualification varieties of first and last authors also increased, particularly first and last authors holding degrees in MD/PhD and first authors holding masters degrees. Female first and last authorship showed an increase. In 1958, female first authors comprised of 3.0% of all the publications compared with 23% in 2016. Similarly, female last authors accounted for 5.2% of all publications in 1958 compared with 20% in 2016. There was also an increase in articles originating from Europe and Asia. In conclusion, there has been a significant increase in authors per article, variety of author degrees, and contribution from international authors. Despite the relative lack of increase in female cardiologists compared to physicians in other specialties in the United States, female authors in The American Journal of Cardiology have increased significantly over this 58-year time period, surpassing the 13% overall female representation within this specialty.