Long-term outcomes following catheter ablation versus medical therapy in patients with persistent atrial fibrillation and heart failure with reduced ejection fraction.

AIMS: The ARC-HF and CAMTAF trials randomized patients with persistent atrial fibrillation (AF) and heart failure (HF) to early routine catheter ablation (ER-CA) versus pharmacological rate control (RC). After trial completion, delayed selective catheter ablation (DS-CA) was performed where clinically indicated in the RC group. We hypothesized that ER-CA would result in a lower risk of cardiovascular hospitalization and death versus DS-CA in this population. METHODS AND RESULTS: Overall, 102 patients were randomized (age 60 ± 11 years, left ventricular ejection fraction [LVEF] 31 ± 11%): 52 to ER-CA and 50 to RC. After 12 months, patients undergoing ER-CA had improved self-reported symptom scores, lower New York Heart Association class (i.e. better functional capacity), and higher LVEF compared to patients receiving RC alone. During a median follow-up of 7.8 (interquartile range 3.9-9.9) years, 27 (54%) patients in the RC group underwent DS-CA and 34 (33.3%) patients died, including 17 (32.7%) randomized to ER-CA and 17 (34.0%) randomized to RC. Compared with DS-CA, a strategy of ER-CA exhibited similar risk of all-cause mortality (adjusted hazard ratio [aHR] 0.89, 95% confidence interval [CI] 0.44-1.77, p = 0.731) and combined all-cause mortality or cardiovascular hospitalization (aHR 0.80, 95% CI 0.43-1.47, p = 0.467). However, analyses according to treatment received suggested an association between CA and improved outcomes versus RC (all-cause mortality: aHR 0.43, 95% CI 0.20-0.91, p = 0.028; all-cause mortality/cardiovascular hospitalization: aHR 0.48, 95% CI 0.24-0.94, p = 0.031). CONCLUSIONS: In patients with persistent AF and HF, ER-CA produces similar long-term outcomes to a DS-CA strategy. The association between CA as a treatment received and improved outcomes means there is still a lack of clarity regarding the role of early CA in selected patients. Randomized trials are needed to clarify this question.

Patterns of Error in Interpretive Pathology.

OBJECTIVES: To demonstrate how the educational presentation and targeted review of cases with discrepant interpretive findings between pathologists can raise awareness for specific diagnostic errors through identification of common overarching patterns of error in interpretive pathology. METHODS: We performed a review of 147 surgical pathology and cytopathology cases of discordances from 23 PowerPoint presentations presented between 2010 and 2017. Pathologists and pathology residents, blinded from the official interpretations, were presented each case and surveyed for their own diagnostic assessments. Survey results were compared with the final/correct interpretations of the signing pathologists. RESULTS: Of the 134 cases with available survey results, there were 87 (64.9%) for which most survey respondents proposed a diagnostic interpretation concordant with the final/correct diagnosis. There were 37 (27.6%) cases for which most survey responses were either wholly or partially discordant with the final/correct diagnosis. For 10 (7.5%) cases, there were equal numbers of concordant and discordant survey responses. CONCLUSIONS: Our analyses of the cases with frequent erroneous diagnoses reveal common patterns of error that are widely applicable and outline specific error-prone interpretive tendencies. Greater awareness for these tendencies, highlighted by presentation of discordant cases, can improve the quality of diagnostic pathology services.