ABSTRACT
Left atrial appendage (LAA) exclusion strategies are increasingly utilized for stroke prevention in lieu of oral anticoagulants. Reductions in bleeding risk and long-term compliance issues bundled with comparable stroke prevention benefits have made these interventions increasingly attractive. Unfortunately, healthcare funding remains limited. Comparative cost economic analyses are therefore critical in optimizing resource allocation. In this review we seek to discourse the cost economics analysis of LAA exclusion over available therapeutic alternatives (warfarin and the new oral anticoagulants (NOACs)). .
ABSTRACT
Atrial fibrillation (AF) is the most common cardiac arrhythmia and despite advancements in rhythm control through direct catheter ablation, maintaining sinus rhythm is not possible in a large proportion of AF patients, who therefore are subject to a rate control strategy only. Nonetheless, in some of these patients pharmacological rate control may be ineffective, often leaving the patient highly symptomatic and at risk of developing tachycardia-induced cardiomyopathy and heart failure (HF). Catheter ablation of the atrioventricular junction (AVJ) with subsequent permanent pacemaker implantation provides definite rate control and represents an attractive therapeutic option when pharmacological rate control is not achieved. In patients with reduced ventricular function, cardiac resynchronization therapy (CRT) should be considered over right ventricular apical (RVA) pacing in order to avoid the deleterious effects associated with a high amount of chronic RVA pacing. Another group of patients that may also benefit from AVJ ablation are HF patients with concomitant AF receiving CRT. In this patient cohort AVJ ablation ensures near 100% biventricular pacing, thus allowing optimization of the therapeutic effects of CRT.
ABSTRACT
OBJECTIVE: The purpose of this study was to assess the incidence, predictors, and prognostic clinical impact of atrial fibrillation (AF) over time after cavotricuspid isthmus (CTI) ablation of typical atrial flutter (AFL). METHODS: This was a follow-up observational study using 408 patients who underwent CTI AFL ablation between 1998 and 2010. The relationships between the different predictors and the outcomes (AF, stroke, and death) were modeled by means of multistate Cox model analyses. RESULTS: The incident rate of AF per 100 person-years during follow-up was 10.2 (95 % CI 8.7-11.8). Prior AF and chronic obstructive pulmonary disease (COPD) were the only independent variables to predict AF occurrence in the population. Their hazard ratios (HRs) were 2.55 (95 % CI 1.84-3.52) and 1.56 (95 % CI 1.08-2.27), respectively. Patients who transitioned to AF had an increased risk of death by an HR of 2.82 (95 % CI 1.88-4.70) and an increased risk of stroke by an HR of 2.93 (95 % CI 1.12-8.90). Age, COPD, and heart failure (HF) were predictive factors of death by HRs of 1.05 (95 % CI 1.00-1.08), 2.85 (95 % CI 1.39-5.83), and 2.72 (95 % CI 1.15-6.40), respectively. Age, smoking, COPD, and HF were predictive factors of death in the group of patients with AF during follow-up. HRs were 1.07 (95 % CI 1.02-1.12), 2.55 (95 % CI 1.55-4.21), 7.60 (95 % CI 3.01-19.16), and 3.07 (95 % CI 1.18-7.95), respectively. CONCLUSIONS: The transition to AF after CTI AFL ablation was high during a long-term follow-up period and maintained over time. Prior AF and COPD were the primary predictors of transition to AF after CTI AFL ablation. Patients who transitioned to AF had an increased risk of stroke and a more than twofold mortality rate. These clinical implications make it necessary to investigate AF after CTI ablation.
