Clinical utility of oesophageal temperature monitoring in AF ablation: An updated meta-analysis and review of literature.

BACKGROUND: Atrial fibrillation (AF) ablation can lead to oesophageal thermal injuries (ETI). These are thought to be the precursor of the much rarer but frequently fatal atrio-oesophageal fistulas. Many centers performing AF ablation routinely use oesophageal temperature monitoring (ETM). This meta-analysis aims to determine the utility of ETM in preventing ETI in the context of radiofrequency catheter ablation of AF. METHODS: A systematic search of PubMed, Embase databases and Cochrane registry was performed comparing ETI between ETM and non-ETM strategies in AF ablation. Data on endoscopically determined ETI, AF recurrence, procedure time and ablation time were extracted. Statistical analyses including subgroup and covariate analyses were performed using random effect model in R platform. RESULTS: ETI were similar in both ETM (n = 864) and non- ETM groups (n = 639) (RR 1.04, 95 % CI 0.34-3.23) across 12 studies. AF recurrence was statistically similar in both groups (IRR 0.92, 95 % CI 0.73-1.17) but showed a lower trend in non-ETM group. Ablation time was numerically lower in the ETM group and procedure time was numerically higher trend in the ETM group; but they were not statistically significant. Covariate analysis found that posterior wall ablation power setting, additional linear ablation, BMI, use of GA or prophylactic PPI after ablation had no significant correlation in the incidence of ETI. CONCLUSION: ETM was not associated with a reduced incidence of ETI during AF ablation. Evidence supporting the routine use of ETM to reduce the risk of ETI or atrio-oesophageal fistulas is lacking.

Greyzone myocardial fibrosis and ventricular arrhythmias in patients with a left ventricular ejection fraction >35.

AIMS: To determine whether myocardial fibrosis and greyzone fibrosis (GZF) on cardiovascular magnetic resonance (CMR) is associated with ventricular arrhythmias in patients with coronary artery disease (CAD) and a left ventricular ejection fraction (LVEF) >35%. METHODS AND RESULTS: In this retrospective study of CAD patients, GZF mass using the 3SD method (GZF3SD) and total fibrosis mass using the 2SD method (TF2SD) on CMR were assessed in relation to the primary, combined endpoint of sudden cardiac death, ventricular tachycardia, ventricular fibrillation, or resuscitated cardiac arrest. Among 701 patients [age: 65.8 ± 12.3 years (mean ± SD)], 28 (3.99%) patients met the primary endpoint over 5.91 years (median; interquartile range 4.42-7.64). In competing risks analysis, a GZF3SD mass ≥5.0 g was strongly associated with the primary endpoint [subdistribution hazard ratio (sHR): 17.4 (95% confidence interval, CI 6.64-45.5); area under receiver operator characteristic curve (AUC): 0.85, P < 0.001]. A weaker association was observed for TF2SD mass ≥23 g [sHR 10.4 (95% CI 4.22-25.8); AUC: 0.80, P < 0.001]. The range of sHRs for GZF3SD mass (1-527) was wider than for TF2SD mass (1-37.6). CONCLUSIONS: In CAD patients with an LVEF >35%, GZF3SD mass was strongly associated with the arrhythmic endpoint. These findings hold promise for its use in identifying patients with CAD and an LVEF >35% at risk of arrhythmic events.

Myocardial Fibrosis as a Predictor of Sudden Death in Patients With Coronary Artery Disease.

BACKGROUND: The "gray zone" of myocardial fibrosis (GZF) on cardiovascular magnetic resonance may be a substrate for ventricular arrhythmias (VAs). OBJECTIVES: The purpose of this study was to determine whether GZF predicts sudden cardiac death (SCD) and VAs (ventricular fibrillation or sustained ventricular tachycardia) in patients with coronary artery disease (CAD) and a wide range of left ventricular ejection fractions (LVEFs). METHODS: In this retrospective study of CAD patients, the presence of myocardial fibrosis on visual assessment (MFVA) and GZF mass in patients with MFVA were assessed in relation to SCD and the composite, arrhythmic endpoint of SCD or VAs. RESULTS: Among 979 patients (mean age [± SD]: 65.8 ± 12.3 years), 29 (2.96%) experienced SCD and 80 (8.17%) met the arrhythmic endpoint over median 5.82 years (interquartile range: 4.1 to 7.3 years). In the whole cohort, MFVA was strongly associated with SCD (hazard ratio: 10.1; 95% confidence interval [CI]: 1.42 to 1,278.9) and the arrhythmic endpoint (hazard ratio: 28.0; 95% CI: 4.07 to 3,525.4). In competing risks analyses, associations between LVEF <35% and SCD (subdistribution hazard ratio [sHR]: 2.99; 95% CI: 1.42 to 6.31) and the arrhythmic endpoint (sHR: 4.71; 95% CI: 2.97 to 7.47) were weaker. In competing risk analyses of the MFVA subcohort (n = 832), GZF using the 3SD method (GZF3SD) >5.0 g was strongly associated with SCD (sHR: 10.8; 95% CI: 3.74 to 30.9) and the arrhythmic endpoint (sHR: 7.40; 95% CI: 4.29 to 12.8). Associations between LVEF <35% and SCD (sHR: 2.62; 95% CI: 1.24 to 5.52) and the arrhythmic endpoint (sHR: 4.14; 95% CI: 2.61 to 6.57) were weaker. CONCLUSIONS: In CAD patients, MFVA plus quantified GZF3SD mass was more strongly associated with SCD and VAs than LVEF. In selecting patients for implantable cardioverter-defibrillators, assessment of MFVA followed by quantification of GZF3SD mass may be preferable to LVEF.

Cardiovascular disease in type 1 diabetes.

Cardiovascular disease (CVD) is a well-recognized complication of diabetes. Although the association of type 2 diabetes with CVD has been well described, the mechanisms, risk stratification and screening strategies of CVD in type 1 diabetes (T1D) are less understood. This review aims to evaluate recent literature and guidelines regarding CVD in T1D. At the cellular level, the early stage of CVD is characterized by endothelial dysfunction. Recent studies have shown that endothelial function is unaffected in younger T1D patients but there is a significant degree of endothelial dysfunction in the older T1D population compared with healthy age-matched controls, highlighting the importance of the endothelial dysfunction in T1D as a major age-dependent cardiovascular risk factor. T1D risk assessment tools have been developed similar to those seen in type 2 diabetes. Foremost among these are the Danish Steno Type 1 risk engine, the Swedish T1D risk score, the Scottish T1D risk score and the QRISK risk calculator. The latter risk prediction tool is used for all patients but contains T1D as an independent risk variable and has the advantage of being derived from, and validated in, a large and diverse population. The latest version (QRISK3) is likely to be recommended for routine use in T1D patients in upcoming guidelines by the National Institute of Clinical Excellence. Mortality in adults with T1D is increasingly due to CVD. This is driven by hyperglycaemia-mediated oxidative stress and vascular inflammation, resulting in atherosclerosis and cardiac autonomic neuropathy. Coronary artery disease is the most significant contributor to CVD and in T1D, has a propensity towards a more silent and severe form. Routine screening of coronary artery disease does not alter outcomes and is therefore not recommended; however, risk prediction tools are being developed to aid identification of high-risk individuals for aggressive risk factor modification strategies.

Quality of life benefits from arrhythmia ablation: A longitudinal study using the C-CAP questionnaire and EQ5D.

AIMS: To investigate long-term efficacy of cardiac ablation for symptomatic arrhythmia by gathering generic and arrhythmia-related quality of life data using patient-reported outcome measures before and after ablation. METHODS: Consecutive patients undergoing cardiac ablation procedures at three sites in the United Kingdom were enrolled (n = 561). Data were collected at baseline, at 8-16 weeks, and 12 months after the ablation with responses from 390 patients received at all three time points. Nonparametric tests were used to identify any changes in patient outcomes due to nonnormal data. RESULTS: There were significant improvements in symptom severity, impact on life scores, EQ-5D-5L indices, and visual analogue score (VAS) scores at pre- versus 3 months and at preablation versus 1 year. Impact on life score showed additional improvement at 1 year versus 3 months, while improvements in symptom severity, EQ-5D-5L indices, and VAS scores continued to be maintained between 3 months and 1 year. CONCLUSION: Cardiac ablation provides patients with arrhythmias relief from symptoms, and results in an improvement in quality of life. Improvements observed at 3 months are maintained at 1 year follow-up.

Questions remain regarding the long-term efficacy of cardiac ablation. We enrolled 561 consecutive patients undergoing ablation procedures at three UK sites. Data were collected at baseline, and at 3 and 12 months. Improvement in symptoms was reported following treatment, with patients continuing to maintain or show continued improvement at 1 year.

Glomerular filtration rate: A prognostic marker in atrial fibrillation-A subanalysis of the AntiThrombotic Agents Atrial Fibrillation.

OBJECTIVE: An increased cardiovascular mortality and morbidity has been widely reported in patients with atrial fibrillation (AF). In this study, a subanalysis of the AntiThrombotic Agents Atrial Fibrillation (ATA-AF) is performed with the aim to evaluate estimated glomerular filtration rate (eGFR) as an independent prognostic marker of cardiovascular mortality and morbidity in patients with AF. METHODS AND RESULTS: The ATA-AF study enrolled 7148 patients with AF, in 360 Italian centers. The eGFR was calculated from data reported in patient notes or hospital database. This post-hoc analysis included 1097 AF patients with eGFR data available and 1-year clinical follow-up. The endpoint was assessed as cardiovascular mortality and/or hospital admission for cardiovascular causes at follow-up. Patients were also divided in two groups according to the eGFR (<60 and ≥60 mL/min/1.73 m2 ). The Kaplan-Meyer curve for the mentioned endpoint showed a higher endpoint incidence in the group of patient with eGFR below 60 mL/min/1.73 m2 (P < 0.001). Using multivariate analysis (Cox regression), a trend toward a higher rate of occurrence of the primary endpoint was observed for eGFR below 60 mL/min/1.73 m2 without reaching the conventional level of statistical significance (hazard ratio [HR] 1.40; 95% confidence interval [CI] 0.99-1.99; P = 0.0572). When eGFR was included in the analysis as continuous variable a significant correlation was observed with the combined endpoint at the Cox regression (HR 0.99, 95% CI 0.98-0.99, P = 0.04). CONCLUSION: The result of this post-hoc analysis indicates that an impaired eGFR is independently associated with worse prognosis among patients with AF.

Patient-Reported Outcomes for Quality of Life Assessment in Atrial Fibrillation: A Systematic Review of Measurement Properties.

BACKGROUND: Atrial fibrillation is a large and growing burden across all types of healthcare. Both incidence and prevalence are expected to double in the next 20 years, with huge impact on hospital admissions, costs and patient quality of life. Patient wellbeing determines the management strategy for atrial fibrillation, including the use of rhythm control therapy and the clinical success of heart rate control. Hence, evaluation of quality of life is an emerging and important part of the assessment of patients with atrial fibrillation. Although a number of questionnaires to assess quality of life in atrial fibrillation are available, a comprehensive overview of their measurement properties is lacking. METHODS AND RESULTS: We performed a systematic review of the measurement properties of atrial fibrillation-specific health-related quality of life questionnaires. Methodological quality was assessed using the Consensus based Standards for selection of health Measurement Instruments (COSMIN) checklist, with measurement properties rated for quality against optimal criteria and levels of evidence. We screened 2,216 articles, of which eight articles describing five questionnaires were eligible for inclusion: Atrial Fibrillation 6 (AF6), Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT), Atrial Fibrillation Quality of Life Questionnaire (AFQLQ), Atrial Fibrillation Quality of Life (AFQoL), and Quality of Life in Atrial Fibrillation (QLAF). Good reliability (internal consistency and test-retest reliability) was demonstrated for AF6, AFEQT, AFQLQ and AFQoL. Content, construct and criterion validity were positively rated only in AFEQT. Responsiveness was positively rated only in AFEQT, but with limited evidence. Overall, AFEQT showed strong positive evidence for 2 of 9 measurement properties, compared to one for AFQoL and none for the remaining questionnaires. INTERPRETATION: Given the low ratings for many measurement properties, no single questionnaire can be recommended, although AFEQT performed strongest. Further studies to robustly assess reliability, validity and responsiveness of AF-specific quality of life questionnaires are required. This review consolidates the current evidence for quality of life assessment in patients with atrial fibrillation and identifies priority areas for future research.

Haemodynamic effects of cardiac resynchronization therapy using single-vein, three-pole, multipoint left ventricular pacing in patients with ischaemic cardiomyopathy and a left ventricular free wall scar: the MAESTRO study.

AIMS: The clinical response to cardiac resynchronization therapy (CRT) is variable. Multipoint left ventricular (LV) pacing could achieve more effective haemodynamic response than single-point LV pacing. Deployment of an LV lead over myocardial scar is associated with a poor haemodynamic response to and clinical outcome of CRT. We sought to determine whether the acute haemodynamic response to CRT using three-pole LV multipoint pacing (CRT3P-MPP) is superior to that to conventional CRT using single-site LV pacing (CRTSP) in patients with ischaemic cardiomyopathy and an LV free wall scar. METHODS AND RESULTS: Sixteen patients with ischaemic cardiomyopathy [aged 72.6 ± 7.7 years (mean ± SD), 81.3% male, QRS: 146.0 ± 14.2 ms, LBBB in 14 (87.5%)] in whom the LV lead was intentionally deployed straddling an LV free wall scar (assessed using cardiac magnetic resonance), underwent assessment of LV + dP/dtmax during CRT3P-MPP and CRTSP. Interindividually, the ΔLV + dP/dtmax in relation to AAI pacing with CRT3P-MPP (6.2 ± 13.3%) was higher than with basal and mid CRTSP (both P < 0.001), but similar to apical CRTSP. Intraindividually, significant differences in the ΔLV + dP/dtmax to optimal and worst pacing configurations were observed in 10 (62.5%) patients. Of the 8 patients who responded to at least one configuration, CRT3P-MPP was optimal in 5 (62.5%) and apical CRTSP was optimal in 3 (37.5%) (P = 0.0047). CONCLUSIONS: In terms of acute haemodynamic response, CRT3P-MPP was comparable an apical CRTSP and superior to basal and distal CRTSP. In the absence of within-device haemodynamic optimization, CRT3P-MPP may offer a haemodynamic advantage over a fixed CRTSP configuration.

Cardiff cardiac ablation patient-reported outcome measure (C-CAP): validation of a new questionnaire set for patients undergoing catheter ablation for cardiac arrhythmias in the UK.

PURPOSE: To formally test and validate a patient-reported outcome measure (PROM) for patients with cardiac arrhythmias undergoing catheter ablation procedures in the UK [Cardiff Cardiac Ablation PROM (C-CAP)]. METHODS: A multicentre, prospective, observational cohort study with consecutive patient enrolment from three UK sites was conducted. Patients were sent C-CAP questionnaires before and after an ablation procedure. Pre-ablation C-CAP1 (17 items) comprised four domains: patient expectations; condition and symptoms; restricted activity and healthcare visits; medication and general health. Post-ablation C-CAP2 (19 items) comprised five domains including change in symptoms and procedural complications. Both questionnaires also included the generic EQ-5D-5L tool (EuroQol). Reliability, validity, and responsiveness measures were calculated. RESULTS: A total of 517 valid pre-ablation and 434 post-ablation responses were received; questionnaires showed good feasibility and item acceptability. Internal consistency was good (Cronbach's alpha >0.7) and test-retest reliability was acceptable for all scales. C-CAP scales showed high responsiveness (effect size >0.8). Patients improved significantly (p < 0.001) following ablation across all disease-specific and global scales. Minimal clinically important difference was calculated. Improvement beyond the smallest detectable change of 9 points (symptom severity scale), 3 points (frequency and duration of symptoms scale), and 8 points (impact on life scale) indicates an important change. Amendments to the C-CAP questionnaires were identified through the validation process and made to produce the final tools. CONCLUSIONS: The final C-CAP questionnaires are valid, reliable, and responsive tools for measuring symptom change, impact, and expectations in patients undergoing ablation for cardiac arrhythmias. C-CAP questionnaires provide a tool with disease-specific and generic domains to explore how cardiac ablation procedures in the UK impact upon patients' lives.

Living on a knife edge-the daily struggle of coping with symptomatic cardiac arrhythmias.

BACKGROUND: In 2010 a retrospective audit was undertaken to assess the viability of using PROMs in patients with symptomatic cardiac arrhythmias having undergone percutaneous arrhythmia ablation. A response rate of 74 % was achieved, with finding suggesting that arrhythmia patients reported a significant impact on their work, social and family life. AIMS: To conduct a qualitative cross sectional survey to understand patients' perspectives of how cardiac arrhythmias affect their daily lives, as part of a program to develop a Patient Reported Outcome Measure (PROM). METHOD: Twenty five patients aged 18 or over, diagnosed with a variety of symptomatic cardiac arrhythmias referred for a cardiac ablation procedure took part in cognitive interviews. These aimed to inform the development of a patient reported outcome measure and to determine factors important to this patient group. Common themes were identified using content analysis. RESULTS: Participants reported that symptoms of their arrhythmia caused them considerable problems and impacted adversely on their quality of life in many ways. This extended through daily routine, work and social activities and also to friends and family, with fear and anxiety being significant factors for most responders. Patients felt their illness was poorly understood, even by health professionals, and often reported that they felt isolated, lacking support and information. CONCLUSION: Symptomatic cardiac arrhythmias are a source of debilitating and life limiting symptoms, having a negative impact on quality of life. Symptoms and related complications are relevant across different arrhythmia substrates and patient groups. TRIAL REGISTRATION: The study is registered on the Clinical Trials website, Identifier NCT01672528.

Establishing content validity in a novel patient reported outcome measure for cardiac arrhythmia ablation patients.

AIM: Preliminary content validity testing of a UK Patient Reported Outcome Measure (PROM) for use in cardiac arrhythmia patients undergoing ablation treatment. METHODS: Twenty five patients diagnosed with symptomatic cardiac arrhythmias participated in qualitative interviews to obtain their perspective of a draft PROM. As part of the process to establish preliminary content validity, patients were asked to complete the questionnaires and to identify missing and redundant items within the PROM, while also reviewing the instructions and formatting. The questionnaires were updated iteratively to reflect patient feedback. RESULTS: Recurring themes were identified during qualitative interviews leading to improvements to the tool. Following modification of the PROM, based on patient feedback, subjects reported that the tool was fully inclusive and easy to comprehend. Patients found the instructions and layout of the tool acceptable and easy to use. CONCLUSION: Qualitative patient interviews are an important part of PROM tool development. In the case of this cardiac ablation PROM, it enabled end users to assess the tool for inclusivity and accessibility, and to ensure that it addressed concerns important to the patient. Cognitive interviews were able to obtain patients' perspectives to establish face validity and content validity of the PROM. This is part of a process which will ensure that this disease-specific PROM measures cardiac arrhythmia patient symptoms and impact on patients' lives accurately and sensitively. The next study will use the PROM prospectively in over 450 arrhythmia patients to prospectively validate the tool. CONDENSED ABSTRACT: Patients diagnosed with symptomatic cardiac arrhythmias provided feedback through cognitive interviews to facilitate improvements in a new disease specific PROM establishing preliminary face and content validity.

Patient reported outcome measures for cardiac ablation procedures: a multicentre pilot to develop a new questionnaire.

AIM: To assess the feasibility of administering Patient Reported Outcomes Measures (PROMs) in patients treated with ablation for cardiac arrhythmias, and to conduct the first stage of development and testing of a new PROM tool. METHODS AND RESULTS: A new tool was developed by a multidisciplinary team and tested alongside an adaptation of the patient perception of arrhythmia questionnaire (PPAQ) and EQ-5D-5L in a multicentre retrospective audit involving 791 consecutive cardiac arrhythmia patients treated with catheter ablation at three UK centres over 13 months. Data were recorded in the National Cardiac Rhythm Management Database, part of the National Institute for Cardiovascular Outcomes Research. The response rate was 71.9% (n = 569). Patients reported significant improvements across all outcomes and impacts, with reductions in symptoms of 51.7% (heart racing), 33.9% (fatigue) 31.8% (heart flutters), 43.5% (dizziness), 38.6% (breathlessness), 44.2% (chest pressure), 33.1% (trouble concentrating), 15.9% (headache), 28.3% (neck pressure), and 23.4% (fainting) (P < 0.001). The mean number of social days affected reduced by 7.49 days/month (P < 0.001); mean work/school days affected/month reduced by 6.26 (P < 0.001); mean GP/hospital visits reduced by 1.36 days/month (P < 0.001). The procedure met patient expectations in 72% of responders. CONCLUSIONS: The high response rate suggests that the use of PROMs in this patient group is feasible, with rates equalling those of the National PROMs Programme. The results showed that patients experienced significant improvements in their quality of life following ablation, while feedback allowed the tools to be improved. Further work is required to validate these tools; however, the findings suggest that PROMs could be useful in the audit of ablation techniques.

Local activation time derived from stored EGM is associated with failure of antitachycardia pacing in patients with implantable defibrillator.

BACKGROUND: Antitachycardia pacing (ATP) is an effective treatment of ventricular tachycardia (VT). However, persistent failure of ATP in some patients is well recognized. METHODS: A method of deriving the local activation time from stored intracardiac electrograms in implantable cardioverter defibrillators is described. Using a case-control design, the local activation times were compared between patients with persistent unsuccessful ATP with comparable controls with successful ATP. RESULTS: The local activation times during VT in patients with failed ATP were longer at 120-180 ms compared with corresponding control patients with successful ATP (60-80 ms). The local activation time expressed as a proportion of VT cycle length in patients with failed ATP compared with patients with successful ATP were 0.40 +/- 0.08 versus 0.19 +/- 0.08 (P = 0.012). CONCLUSION: A novel method of deriving local activation time is described, and delayed local activation time may explain failure of ATP in terminating VT in some patients.

Verification of electrical isolation of pulmonary veins following left atrial circumferential ablation may require sinus rhythm.

A 67-year-old female with symptomatic paroxysmal atrial fibrillation (AF) underwent left atrial circumferential ablation, and during the procedure, she developed AF. Once the ablation was complete, the left upper pulmonary vein (LUPV) appeared to continue in a rapid disorganized rhythm, despite further attempts at isolating this vein. When the patient was electrically cardioverted to sinus rhythm to assist mapping, the LUPV remained in a disorganized rhythm, pulmonary vein (PV) fibrillation. This case illustrates a possible pitfall in confirming complete isolation of the PVs during AF.

Coronary endarterectomy: impact on morbidity and mortality when combined with coronary artery bypass surgery.

BACKGROUND: The results of coronary endarterectomy (CE) performed in addition to coronary artery bypass grafting (CABG) have been controversial. We aimed to examine the impact of CE performed in addition to CABG when compared with CABG alone in our unit. METHODS: Patients who had CABG between January 1995 and December 2001 were included. They were divided into two groups, the CABG-only group and CABG and CE group. The following outcomes were compared: perioperative myocardial infarction, postoperative ventricular arrhythmias, cerebrovascular accident, renal impairment, and early mortality. RESULTS: Of 5,782 patients who underwent CABG, 461 patients (8.6%) required CE in addition to CABG. There was a higher mortality and incidence of postoperative renal impairment in the group of patients who had CABG and CE, with no significant difference in other outcomes. However, the patients in the CABG and CE group had a higher incidence of male sex, previous myocardial infarctions, preoperative renal impairment, and poor left ventricular function, with longer cross-clamp and cardiopulmonary bypass times than in the CABG-only patients. Although female sex, renal impairment, nonelective surgery, impaired left ventricular function, and peripheral vascular disease were associated with increased mortality in all the patients, and use of statins and aspirin was associated with a reduction in mortality, CE was not a predictor of mortality. Furthermore, on propensity scores analysis, CE was not associated with increased mortality. CONCLUSIONS: Coronary endarterectomy when combined with CABG seemed to be associated with a higher mortality than isolated CABG in our study groups, but this is related to comorbidities of these patients rather than the CE.