Galectin-3, Inflammation, and the Risk of Atrial High-Rate Episodes in Patients with Dual Chamber Pacemakers.

Atrial high-rate episodes (AHREs) are atrial tachyarrhythmias that are exclusively detected by cardiac implantable electronic devices (CIEDs) with an atrial lead. The objective of this study was to investigate the incidence and predictive factors for AHREs, and to evaluate the ability of inflammation biomarkers to predict the occurrence of AHREs. 102 patients undergoing CIED procedure who received a dual chamber pacemaker were included. CIED interrogation was performed 1 year after the implantation procedure. Patients were divided into groups according to the occurrence of AHREs, which was the primary endpoint of the study. The mean age of the patients was of 73 ± 8.6 years and 48% were male. The incidence of AHREs was 67% at 1 year follow-up. Patients with AHREs were older, had higher left atrial indexed volume (LAVi), higher baseline galectin-3 levels (1007.5 ± 447.3 vs. 790 ± 411.7 pg/mL) and received betablockers more often, along with amiodarone and anticoagulants. Interestingly, the CHADSVASC score did not differ significantly between the two groups. A cut-off value of galectin > 990 pg/mL predicted AHREs with moderate accuracy (AUC of 0.63, 95% CI 0.52 to 0.73, p = 0.04), and this association was confirmed in the univariate regression analysis (OR 1.0012, 95% CI 1.0001 to 1.0023, p = 0.0328). However, based on the multivariate regression analysis, galectin lost its prognostic significance under the effect of LAVi, which remained the only independent predictor of AHREs (OR 1.0883, 95% CI 1.0351 to 1.1441, p = 0.0009). AHREs are common in CIEDs patients. Galectin-3 may bring additional data in the prediction of AHREs.

Particularities of Catheter Ablation in Women with Atrial Fibrillation and Associated Ischemic Heart Disease.

BACKGROUND: Atrial fibrillation is more common in men, but in the presence of ischemic heart disease, this arrhythmia is more frequent in women. However, like in coronary heart disease, women with atrial fibrillation are suboptimally treated. METHODS: To identify particularities of ablation, in women with atrial fibrillation and ischemic heart disease. RESULTS: 29 women and 26 men, with documented ischemic heart disease and atrial fibrillation, who underwent catheter ablation, were admitted in the study. No significant differences were registered regarding the heart rate control treatment. Electrical cardioversion was significantly higher in men, while pharmacological cardioversion was predominantly recommended in women. The ablation was performed later in women, after 2.55 ± 1.84 years versus 1.80 ± 1.05 in men (p = 0.05). The time elapsed until the ablation was performed was statistically correlated with atypical symptomatology and with the number of antiarrhythmics used prior to the ablation. There were no significant differences for the relapse of atrial fibrillation at 3 months. Quality of life at 3 months after ablation was increased in both groups. CONCLUSION: Catheter ablation is performed much later in women, and the causes responsible for this delay would be more atypical symptoms and a greater number of antiarrhythmics tried before the ablation.

Empirical superior vena cava isolation in patients undergoing repeat catheter ablation procedure after recurrence of atrial fibrillation.

BACKGROUND: Although the ectopic foci responsible for initiating atrial fibrillation (AF) are usually located in the pulmonary veins (PVs), non-PV sources may initiate AF in approximately 11% of unselected patients with paroxysmal or persistent AF. The superior vena cava (SVC) is one of the most frequent non-PV origins for initiating AF. This study aims to investigate the effect of empirical SVC isolation in redo AF ablation procedures. METHODS: Consecutive patients undergoing redo AF ablation procedures using a high-power short-duration protocol (HPSD) (50 W; ablation index guided; target AI 350 for posterior wall ablation, AI 450 for anterior wall ablation; CARTO 3 mapping system) were included. Patients with SVC isolation were compared to patients without SVC isolation. Periprocedural parameters and complications were recorded and analyzed. Short-term endpoints included intrahospital AF recurrence, midterm endpoint AF freedom after 3 months, and long-term endpoint AF freedom after 12 months. RESULTS: A total of 276 patients underwent repeat ablation for recurrent AF (67 ± 10 years; 57% male; 31.5% paroxysmal AF). The patients were divided into two groups: redo procedures with SVC isolation vs redo procedure without SVC isolation. Additional LA substrate modification was done based on intraprocedural voltage maps. Baseline characteristics did not differ significantly between the two groups. Median procedure time was 85.4 ± 27.1 min with ablation times of 14.0 ± 8.5 min. Intrahospital AF recurrence occurred in 32 patients (12%) with no difference among both groups: 17 patients (13%) SVC vs 15 patients (10%) No-SVC; p = 0.416. At 3-month follow-up, 47 (17%) presented an AF recurrence during the blanking period: 25 patients (19%) SVC vs 22 patients (15%) No-SVC; p = 0.304). After 12 months, 202 (73%) of all patients were in stable sinus rhythm with no significant difference between the two groups: 93 patients (73%) SVC vs 109 patients (74%) No-SVC; p = 0.853). No significant differences were noted when dividing the patients in paroxysmal or persistent AF with and without SVC isolation. CONCLUSIONS: In our series of repeat AF ablation procedures, the addition of empirical SVC isolation to Re-PVI and LA substrate modification did not influence AF recurrence rates. This strategy can however be safe and useful in patients in whom SVC is identified as a trigger of AF.

Safety aspects of very high power very short duration atrial fibrillation ablation using a modified radiofrequency RF-generator: Single-center experience.

INTRODUCTION: High power short duration (HPSD) ablation proved to be an effective and safe ablation technique for atrial fibrillation (AF). In former case series, a significant amount of postablation coagulation at the catheter tip as well as silent cerebral lesions (SCL) in postprocedural cerebral magnetic resonance (cMRI) have been identified in patients undergoing de-novo AF ablations with very high power 90 W short duration (vHPvSD) ablations using the QDot ablation catheter in combination with a novel RF generator (nGEN, Biosense Webster). Therefore, the RF generator software has been recently modified. METHODS AND RESULTS: Consecutive patients undergoing a first AF ablation including pulmonary vein isolation (PVI) with vHPvSD (90 W, with a predefined ablation time of 3 s at posterior left atrium (LA) wall sites and 4 s at other ablation sites) using the QDOT Micro ablation catheter (Biosense Webster) in conjunction with the technically modified nGEN RF generator (software V1c; Biosense Webster) were included. Procedural characteristics including first-pass isolation per pulmonary vein (PV) pair and early reconnection location within the 30-min waiting period were recorded. In all patients postablation endoscopy to document any thermal esophageal injury (EDEL) and in eligible patients a cMRI to detect silent cerebral events (SCEs)/lesions were performed. All acute procedure-related complications were recorded during the time until hospital discharge. Furthermore, short-term and midterm success after 3 and 6-12 months of follow-up was investigated. In total, 34 consecutive patients (67 ± 9 years; 62% male; 68% paroxysmal AF) were included. First-pass isolation of all PVs was achieved in 6/34 (18%) patients. First-pass isolation was seen in 37/68 (54%) of PV pairs. Early reconnection occurred in 11 (32%) patients (including reconnections at posterior LA wall sites n = 6 and at nonposterior sites n = 5). No patient had an EDEL (0%). In 6/23 (26%) patients undergoing postablation cerebral MRI SCEs were identified. In six patients, coagulation on the catheter tip was detected at the end of the procedure. No further peri- or postprocedural complications were detected. Early AF recurrence before discharge was seen in 1/34 (3%) of the patients included in this study. Within 3 months 10/34 (29%) revealed AF recurrence during blanking period. After a mean follow-up of 7 months, 31/34 (88%) patients revealed sinus rhythm. CONCLUSION: AF ablation using 90 W vHPvSD with a specialized ablation catheter in conjunction with a recently modified RF generator was associated with no EDEL in the whole study cohort and 26% SCEs in a subgroup of patients undergoing acute postablation cerebral MRI. Accordingly, to our previously published results, a relevant number of catheter tip coagulations was identified in this patient cohort even after modifications of the RF generator. The vHPvSD ablation technique using the present and the previous generator seems to be associated with a very low rate of esophageal injury. However, the recently revised generator software also produced a relevant number of catheter tip coagulum formation and SCEs.

Acute oesophageal safety of high-power short duration with 50 W for atrial fibrillation ablation.

AIMS: Pulmonary vein isolation (PVI) using radiofrequency (RF) ablation is an effective treatment option for patients with atrial fibrillation (AF). This study aims to investigate the safety of high-power short duration (HPSD) with emphasis on oesophageal lesions after PVI. METHODS AND RESULTS: Consecutive patients undergoing AF ablation with HPSD (50 W; ablation index (AI)-guided; target AI 350 for posterior wall ablation, AI 450 for anterior wall ablation) using the ThermoCool SmartTouch SF catheter were included. Patients underwent post-ablation oesophageal endoscopy to detect and categorize thermal oesophageal injury (EDEL). Occurrence and risk factors of oesophageal lesions and perforating complications were analysed. A total of 1033 patients underwent AF ablation with HPSD. Of them, 953 patients (67.6 ± 9.6 years; 58% male; 43% paroxysmal AF; 68% first PVI) underwent post-procedural oesophageal endoscopy and were included in further analyses. Median procedure time was 82.8 ± 24.4 min with ablation times of 16.1 ± 9.2 min. Thermal oesophageal injury was detected in 58 patients (6%) (n = 29 Category 1 erosion, n = 29 Category 2 ulcerous). One patient developed oesophageal perforation (redo, 4th AF ablation). No patient died. Using multivariable regression models, increased total ablation time [odds ratio (OR) 1.029, P = 0.010] and history of stroke (OR 2.619, P = 0.033) were associated with increased incidence of EDEL after AF ablation, whereas increased body mass index was protective (OR 0.980, P = 0.022). CONCLUSION: Thermal oesophageal lesions occur in 6% of HPSD AF ablations. The risk for development of perforating complications seems to be low. Incidence of atrio-oesophageal fistula (0.1%) is comparable to other reported series about RF ablation approaches.

Pathogenesis of Autoimmune Hepatitis-Cellular and Molecular Mechanisms.

Pediatric autoimmune liver disorders include autoimmune hepatitis (AIH), autoimmune sclerosing cholangitis (ASC), and de novo AIH after liver transplantation. AIH is an idiopathic disease characterized by immune-mediated hepatocyte injury associated with the destruction of liver cells, causing inflammation, liver failure, and fibrosis, typically associated with autoantibodies. The etiology of AIH is not entirely unraveled, but evidence supports an intricate interaction among genetic variants, environmental factors, and epigenetic modifications. The pathogenesis of AIH comprises the interaction between specific genetic traits and molecular mimicry for disease development, impaired immunoregulatory mechanisms, including CD4+ T cell population and Treg cells, alongside other contributory roles played by CD8+ cytotoxicity and autoantibody production by B cells. These findings delineate an intricate pathway that includes gene to gene and gene to environment interactions with various drugs, viral infections, and the complex microbiome. Epigenetics emphasizes gene expression through hereditary and reversible modifications of the chromatin architecture without interfering with the DNA sequence. These alterations comprise DNA methylation, histone transformations, and non-coding small (miRNA) and long (lncRNA) RNA transcriptions. The current first-line therapy comprises prednisolone plus azathioprine to induce clinical and biochemical remission. Further understanding of the cellular and molecular mechanisms encountered in AIH may depict their impact on clinical aspects, detect biomarkers, and guide toward novel, effective, and better-targeted therapies with fewer side effects.

[A 19-year-old woman with palpitations and mitral regurgitation]. / Eine 19-jährige Patientin mit Palpitationen und Mitralinklappensuffizienz.

A young woman presented with palpitations. Holter monitoring revealed frequent premature ventricular complexes; echocardiography showed high-degree mitral regurgitation due to mitral valve prolapse. While mitral valve replacement or repair were being discussed, a different therapy was applied after further diagnostic work-up of the patient which in retrospect appears even more efficient.

Impact of Three-Dimensional Strain on Major Adverse Cardiovascular Events after Acute Myocardial Infarction Managed by Primary Percutaneous Coronary Intervention-A Pilot Study.

BACKGROUND: Three-dimensional speckle-tracking echocardiography (3D-STE) allows simultaneous assessment of multidirectional components of strain. However, there are few data on its usefulness to predict prognosis in patients with acute myocardial infarction (AMI). The objective of our pilot study was to evaluate the prognostic value of four different 3D-STE parameters (global longitudinal strain (GLS-3D), global circumferential strain (GCS-3D), global radial strain (GRS-3D), and global area strain (GAS)) in AMI, after successful revascularization by primary PCI. METHODS: We enrolled 94 AMI patients (66 ± 13 years, 56% men) who underwent coronary angiography. All patients had been 3D-STE assessed and followed-up for 1 year for the occurrence of MACE. RESULTS: A total of 25 MACE were recorded over follow-up. Cut-off values of -17% for GAS (HR = 3.1, 95% CI: 1.39-6.92, p = 0.005), -12% for GCS-3D (HR = 3.06, 95% CI: 1.36-6.8, p = 0.006), -10% for GLS-3D (HR = 3.04, 95% CI: 1.36-6.78, p = 0.006), and 25% for GRS-3D (HR = 2.89, 95% CI: 1.29-6.46, p = 0.009) showed moderate accuracy in MACE prediction. Multivariate regression showed that GAS (HR = 1.1, 95% CI: 1.03-1.16), GLS-3D (HR = 1.13, 95% CI: 1.03-1.26), and GCS-3D (HR = 1.13, 95% CI: 1.03-1.23) remained independent predictors of MACE (HR = 1.07, 95% CI: 1.01-1.14 for GAS, and HR = 1.1, 95% CI: 1.01-1.2 for GCS-3D). However, post hoc power analysis indicated adequate sample size (power of 80%) only for GAS and GCS-3D for the ROC curve analysis and for GAS, GCS-3D, and GRS-3D for the log-rank test. CONCLUSION: Patients with AMI might benefit from early risk stratification with the aid of 3D-STE measurements, particularly GAS and GCS-3D, but larger studies are necessary to determine the optimal cut-off values to predict MACE.

Formula to estimate left atrial volume using antero-posterior diameter in patients with catheter ablation of atrial fibrillation.

ABSTRACT: In patients undergoing atrial fibrillation (AF) ablation, an enlarged left atrium (LA) is a predictor of procedural failure as well as AF recurrence on long term. The most used method to assess LA size is echocardiography-measured diameter, but the most accurate remains computed tomography (CT).The aim of our study was to determine whether there is an association between left atrial diameters measured in echocardiography and the left atrial volume determined by CT in patients who underwent AF ablation.The study included 93 patients, of whom 60 (64.5%) were men and 64 (68.8%) had paroxysmal AF, who underwent AF catheter ablation between January 2018 and June 2019. Left atrial diameters in echocardiography were measured from the long axis parasternal view and the LA volume in CT was measured on reconstructed three-dimensional images.The LA in echocardiography had an antero-posterior (AP) diameter of 45.0 ±â€Š6 mm (median 45; Inter Quartile Range [IQR] 41-49, range 25-73 mm), longitudinal diameter of 67.5 ±â€Š9.4 (median 66; IQR 56-88, range 52-100 mm), and transversal diameter of 42 ±â€Š8.9 mm (IQR 30-59, range 23-64.5 mm). The volume in CT was 123 ±â€Š29.4 mL (median 118; IQR 103-160; range 86-194 mL). We found a significant correlation (r = 0.702; P < .05) between the AP diameter and the LA volume. The formula according to which the AP diameter of the LA can predict the volume was: LA volume = AP diam3 + 45 mL.There is a clear association between the left atrial AP diameter measured on echocardiography and the volume measured on CT. The AP diameter might be sufficient to determine the increase in the volume of the atrium and predict cardiovascular outcomes.

Value of Left Atrial Appendage Function Measured by Transesophageal Echocardiography for Prediction of Atrial Fibrillation Recurrence after Radiofrequency Catheter Ablation.

Atrial fibrillation (AF) recurrence after radiofrequency catheter ablation (RFCA) remains a challenging issue. This study aims to explore the left atrial appendage function by transesophageal echocardiography (TEE) and assess its value in predicting AF recurrence following RFCA in paroxysmal AF patients. Eighty-one patients with paroxysmal AF that underwent RFCA were recruited. TEE was performed before ablation with the assessment of left atrial appendage emptying flow velocity (LAAeV). AF recurrence occurred in 24 patients (29.6%) within 12 months after RFCA. The left atrium diameter (LAD) and left atrium volume index (LAVI) were both significantly higher in the recurrence group compared to the non-recurrence group, while the LAAeV was significantly lower in the recurrence group. LAD, LAVi and LAAeV were univariately significant risk factors for AF recurrence after ablation. Based on receiver operating curve (ROC), LAAeV < 40.5 cm/s, LAVi > 40.5 mL and LAD > 41 mm were identified as cut-off values for predicting AF recurrence. In multivariate regression analysis LAAeV < 40.5 cm/s (HR 8.194, 95% CI 2.980-22.530, p < 0.001) was identified as the only statistically significant independent predictor of AF recurrence, as the statistical significance threshold was not achieved for LAVI > 40.5 mL and LAD > 41 mm (p = 0.319; p = 0.507, respectively). A low LAAeV was the only important independent predictor of AF recurrence within 1 year after first RFCA.

The role of intracardiac echocardiography in reducing radiation exposure during atrial fibrillation ablation.

AIMS: Intracardiac echocardiography (ICE) is a relatively young technique used during complex electrophysiology proce-dures, such as atrial fibrillation (AF) ablation. The aim of this study was to assess whether the use of ICE modifies the radia-tion exposure at the beginning of the learning curve in AF ablation. MATERIALS AND METHODS: In this retrospective study, 52 patients, in which catheter ablation for paroxysmal or persistent AF was performed, were included. For 26 patients we used ICE guidance together with fluoroscopy, whereas for the remaining 26 patients we used fluoroscopy alone, all supported by electroanatomical mapping. We compared total procedure time and radiation exposure, including fluoroscopy dose and time between the two groups and along the learning curve. RESULTS: Most of the patients included were suffering from paroxysmal AF (40, 76%), pulmonary vein isolation being performed in all patients, without secondary ablation sites. The use of ICE was associated with a lower fluoroscopy dose (11839.60±6100.6 vs. 16260.43±8264.5 mGy, p=0.041) and time (28.00±12.5 vs. 42.93±12.7 minutes, p=0.001), whereas the mean procedure time was similar between the two groups (181.54±50.3 vs 197.31±49.8 minutes, p=0.348). Radiation exposure was lower in the last 9 months compared to the first 9 months of the study (p<0.01), decreasing gradually along the learning curve. CONCLUSIONS: The use of ICE lowers radiation exposure in AF catheter ablation from the beginning of the learning curve, without any difference in terms of acute safety or efficacy. Aware-ness towards closest to zero radiation exposure during electrophysiology procedures should increase in order to achieve better protection for both patient and medical staff.

Atrial high-rate episodes: a comprehensive review.

Cardiac electronic implantable devices (CIEDs) have the ability to monitor, store and interpret complex arrhythmias, which has generated a new arrhythmic entity: atrial high-rate episodes (AHRE). AHRE are atrial tachyarrhythmias, detected only by CIEDs. They are widely considered a precursor to atrial fibrillation (AF) but can also be represented by other kinds of supraventricular arrhythmias such as atrial flutter or atrial tachycardia. CIED-detected AHRE are associated with an increased risk of stroke, but the risk is significantly lower than the stroke risk of clinical AF. Moreover, there seems to be no temporal correlation between AHRE and thromboembolic events. Because of the current gaps in evidence, the appropriate management of this arrythmia can be challenging. In this review we take into account the epidemiology behind AHRE, predictive factors, clinical impact and management of this arrhythmia.

The role of multimodal imaging in the diagnosis of an asymptomatic patient with congenital anomaly.

Anomalous left coronary artery from the pulmonary artery (ALCAPA) syndrome is a rare congenital coronary anomaly, which can cause potentially fatal complications, such as heart failure, myocardial infarction and sudden cardiac death. Only a few patients left untreated survive to adulthood. We highlight the importance of multimodal imaging in the diagnosis of ALCAPA syndrome in a young asymptomatic female patient with inducible ischemia on exercise. The patient was successfully treated with surgery.

Understanding the role of echocardiography in remodeling after acute myocardial infarction and development of heart failure with preserved ejection fraction.

Despite the use of reperfusion therapies in the last decades, acute myocardial infarction further remains one of the most frequent causes of mortality. This is mainly caused by changes in the ventricular architecture leading to ventricular remodeling, followed by progressive development of heart failure. Transthoracic echocardiography is a non-invasive instrument which can provide information about the extent of the ischemic process and its consequences but can also predict the outcomes after myocardial infarction. Although standard echocardiographic parameters are currently used for risk stratification of these patients, they might not truly reflect left ventricular systolic dysfunction in acute myocardial infarct patients, since the detection of subtle changes in the myocardial function is beyond their limits. The aim of this review is to underline the use of advanced echocardiographic parameters in identifying patients at risk for developing post-acute myocardial infarction heart failure and subsequent adverse events. Advanced echocardiographic parameters derived from speckle tracking echocardiography provide a detailed assessment on the global and regional left ventricular deformation. Therefore, speckle tracking echocardiography has a major role in predicting the prognosis of acute myocardial infarction patients and particularly in the development ofsubsequent heart failure, which might be prevented with early initiation of adequate therapy.

Variation of the PR interval for confirming ventricular pre-excitation on a 12-lead ECG.

We present the case of a 14-year-old female patient with recurrent episodes of paroxysmal supraventricular tachycardia (PSVT). Her ECG showed a PR interval of 160 ms in lead II, and a delta wave pattern in leads V2 and V3, with a normal QRS interval of 100 ms. We analyzed the three criteria for confirmation of minimal pre-excitation: (i) absence of a Q wave in V6; (ii) presence of an R wave in V1 and (iii) absence of an R wave in avR. The 3 criteria were not met and failed to establish a diagnosis of ventricular pre-excitation. The electrophysiological study confirmed the presence of a left accessory pathway. A new criterion was analyzed: the variation of the PR interval on the same ECG. A difference of >30 ms was successful to confirm the presence of an accessory pathway before ablation and its absence after catheter ablation.