Can Pre-Ablation Biomarkers Be Used to Predict Arrhythmia Recurrence after Ablation Index-Guided Atrial Fibrillation Ablation? / Os Biomarcadores podem ser Utilizados para Prever Recorrência de Arritmia após a Ablação de Fibrilação Atrial Guiada pelo Ablation-Index?

BACKGROUND: Ablation Index (AI) software has allowed better atrial fibrillation (AF) ablation results, but recurrence rates remain significant. Specific serum biomarkers have been associated with this recurrence. OBJECTIVES: To evaluate whether certain biomarkers could be used (either individually or combined) to predict arrhythmia recurrence after AI-guided AF ablation. METHODS: Prospective multicenter observational study of consecutive patients referred for AF ablation from January 2018 to March 2021. Hemoglobin, brain natriuretic peptide (BNP), C-reactive protein, high sensitivity cardiac troponin I, creatinine clearance, thyroid-stimulating hormone (TSH) and free thyroxine (FT4) were assessed for their ability to predict arrhythmia recurrence during follow-up. Statistical significance was accepted for p values of<0.05. RESULTS: A total of 593 patients were included - 412 patients with paroxysmal AF and 181 with persistent AF. After a mean follow-up of 24±6 months, overall single-procedure freedom from atrial arrhythmia was 76.4%. Individually, all biomarkers had no or only modest predictive power for recurrence. However, a TSH value >1.8 µUI/mL (HR=1.82 [95% CI, 1.89-2.80], p=0.006) was an independent predictor of arrhythmia recurrence. When assessing TSH, FT4 and BNP values in combination, each additional "abnormal" biomarker value was associated with a lower freedom from arrhythmia recurrence (87.1 % for no biomarker vs. 83.5% for one vs. 75.1% for two vs. 43.3% for three biomarkers, p<0.001). Patients with three "abnormal" biomarkers had a threefold higher risk of AF recurrence compared with no "abnormal" biomarker (HR=2.88 [95% CI, 1.39-5.17], p=0.003). CONCLUSIONS: When used in combination, abnormal TSH, FT4 and BNP values can be a useful tool for predicting arrhythmia recurrence after AI-guided AF ablation.

FUNDAMENTO: O software ablation index (AI) permitiu melhorar os resultados da ablação de fibrilação atrial (FA), mas as taxas de recorrência permanecem significativas. Biomarcadores séricos específicos têm sido associados a essa recorrência. OBJETIVOS: Avaliar se certos biomarcadores podem ser utilizados (individualmente ou combinados) para predizer a recorrência de FA pós ablação guiada pelo AI. MÉTODOS: Estudo multicêntrico, observacional, prospectivo de pacientes consecutivos, encaminhados para ablação de FA de janeiro de 2018 a março de 2021. Hemoglobina, peptídeo natriurético cerebral (BNP), proteína C reativa, troponina I ultrassensível, clearance de creatinina, Hormônio Tireoestimulante (TSH), e Tiroxina livre (T4) foram avaliados quanto à capacidade de prever a recorrência de arritmias durante o acompanhamento. Valores de p <0,05 foram aceitos como estatisticamente significativos. RESULTADOS: Um total de 593 pacientes foram incluídos ­ 412 com FA paroxística e 181 com FA persistente. Durante o seguimento médio de 24±6 meses, 76,4% não apresentaram recidiva após ablação. Individualmente, os biomarcadores demonstraram um valor preditivo baixo ou nulo para recorrência. No entanto, TSH >1,8 µUI/mL [HR=1,82 (IC95%, 1,89-2,80), p=0,006] foi um preditor independente de recorrência. Avaliando-se a combinação de TSH, FT4 e BNP, a adição de cada valor "anormal" foi associada a uma menor sobrevida livre de recorrência (87,1% se nenhum vs. 83,5% se um vs. 75,1% se dois vs. 43,3% se três biomarcadores, p<0,001). Doentes com três biomarcadores "anormais" apresentaram três vezes maior probabilidade de recorrência de FA, comparativamente aos que não apresentaram nenhum biomarcador "anormal" (HR=2,88 [IC95%, 1,39-5,17], p=0,003). CONCLUSÕES: Quando combinados, valores anormais de TSH, FT4 e BNP podem ser uma ferramenta útil para prever a recorrência de FA pós ablação guiada pelo AI.

Mid-term outcomes after catheter ablation in patients with congenital heart disease.

INTRODUCTION: Cardiac arrhythmias are a major concern in patients with CHD. The purpose of this study was to evaluate the long-term outcomes in patients with CHD submitted to catheter ablation. MATERIALS AND METHODS: Observational retrospective study of patients with CHD referred for catheter ablation from January 2016 to December 2021 in a tertiary referral centre. Acute procedural endpoints and long-term outcomes were assessed. RESULTS: A total of 44 ablation procedures were performed in 36 CHD patients (55% male, mean age 43 ±3 years). Fifty-four arrhythmias were ablated: 23 cavotricuspid isthmus atrial flutters, 10 atrial re-entrant tachycardias, eight focal atrial tachycardias, eight atrial fibrillations, three atrioventricular re-entrant tachycardias, and two ventricular tachycardias. During a median follow-up time of 37 months (interquartile range 12-51), freedom from arrhythmia recurrence was achieved in 93%, with 1.2 procedures per patient (18% with anti-arrhythmic drugs). There were no adverse events related to catheter ablation. No predictors of recurrence were identified. CONCLUSION: In patients with CHD, catheter ablation presents a high mid-term efficacy while maintaining a safe profile.

Conservative management of pneumopericardium: A case of unexpected success.

A 79-year-old male with severe aortic stenosis was admitted with syncope and cranioencephalic traumatism with major nasal hemorrhage. While being prepared for surgical aortic valve replacement, a high-degree atrioventricular block was detected and a definite pacemaker was implanted.

Ostial vs. wide area circumferential ablation guided by the Ablation Index in paroxysmal atrial fibrillation.

AIMS: Pulmonary vein isolation (PVI) guided by the Ablation Index (AI) has shown high acute and mid-term efficacy in the treatment of paroxysmal atrial fibrillation (AF). Previous data before the AI-era had suggested that wide-area circumferential ablation (WACA) was preferable to ostial ablation. However, with the use of AI, we hypothesize that ostial circumferential ablation is non-inferior to WACA and can improve outcomes in paroxysmal AF. METHODS AND RESULTS: Prospective, multicentre, non-randomized, non-inferiority study of consecutive patients were referred for paroxysmal AF ablation from January 2020 to September 2021. All procedures were performed using the AI software, and patients were separated into two different groups: WACA vs. ostial circumferential ablation. Acute reconnection, procedural data, and 1-year arrhythmia recurrence were assessed. During the enrolment period, 162 patients (64% males, mean age of 60 ± 11 years) fulfilled the study inclusion criteria-81 patients [304 pulmonary vein (PV)] in the WACA group and 81 patients (301 PV) in the ostial group. Acute PV reconnection was identified in 7.9% [95% confidence interval (CI), 4.9-11.1%] of PVs in the WACA group compared with 3.3% (95% CI, 1.8-6.1%) of PVs in the ostial group [P < 0.001 for non-inferiority; adjusted odds ratio 0.51 (95% CI, 0.23-0.83), P = 0.05]. Patients in the WACA group had longer ablation (35 vs. 29 min, P = 0.001) and procedure (121 vs. 102 min, P < 0.001) times. No significant difference in arrhythmia recurrence was seen at 1-year of follow-up [11.1% in WACA vs. 9.9% in ostial, hazard ratio 1.13 (95% CI, 0.44-1.94), P = 0.80 for superiority]. CONCLUSION: In paroxysmal AF patients treated with tailored AI-guided PVI, ostial circumferential ablation is not inferior to WACA with regard to acute PV reconnection, while allowing quicker procedures with less ablation time.

His bundle pacing and left bundle branch area pacing: Feasibility and safety.

INTRODUCTION AND OBJECTIVES: There has been increasing interest in pacing methods that provide physiological stimulation, such as His bundle pacing (HBP) or left bundle branch area pacing (LBBAP). Our goal was to assess the feasibility and safety of these techniques. METHODS: Prospective observational single-center study evaluating 46 patients with indication for a pacemaker that attempted HBP or LBBAP from July 2020 to November 2021. Procedural endpoints and pacing parameters were assessed and compared at implantation and three-month follow-up. RESULTS: Overall acute procedural success was achieved in 96% of the cases. Successful HBP was achieved in 91% of the patients and all patients for LBBAP. During implantation, HBP patients presented a higher capture threshold (0.80 [0.55-1.53] V vs. 0.70 [0.40-0.90] V, p=0.08) and lower R-wave amplitude (4.0 [2.9-6.2] mV vs. 7.8 [5.5-10.5] mV, p=0.001) compared to LBBAP patients. There was no difference between groups, either acutely or at 3-months, regarding paced QRS duration (125±22 ms vs. 133±16 ms, p=0.08; 118±16 ms vs. 124±14 ms, p=0.19). Although procedural time was similar with both techniques (95 [75-139] min vs. 95 [74-116] min, p=0.79), fluoroscopy time was significantly reduced during LBBAP (8.1 [5.3-13.4] min vs. 4.1 [3.1-11.3] min, p=0.05). At 3 months of follow-up, the pacing threshold remained with a stable profile in HBP as in LBBAP (1.25 [0.75-2.00] V, p=0.09 and 0.60 [0.50-0.80] V, p=0.78), respectively. The need for re-intervention occurred in 3 (6.5%) HBP cases during follow-up. CONCLUSION: This first national study demonstrates the feasibility and safety of the HBP and LBBAP in patients with pacemaker indication.

Glycoprotein IIb/IIIa inhibitor use in cardiogenic shock complicating myocardial infarction: The Portuguese Registry of Acute Coronary Syndromes.

INTRODUCTION AND OBJECTIVES: Cardiogenic shock (CS) complicates 5-10% of cases of myocardial infarction (MI). Whether glycoprotein IIb/IIIa inhibitors (GPIs) are beneficial in these patients is controversial. Our aim is to assess the prognostic impact of GPI use on in-hospital mortality and outcomes in patients with MI and CS undergoing percutaneous coronary intervention (PCI). METHODS: Between October 2010 and December 2019, 27578 acute coronary syndrome (ACS) patients were included in the multicenter Portuguese Registry of Acute Coronary Syndromes. Of these, 357 with an MI complicated by CS were included in the analysis and grouped based on whether they received GPI therapy (with GPI, n=107 and without GPI, n=250). The primary endpoint was in-hospital mortality. Secondary endpoints included successful PCI and in-hospital reinfarction and major bleeding. RESULTS: Demographics and cardiovascular risk factors did not differ between groups. ST-elevation MI patients were more likely to receive GPIs (95% vs. 83%, p=0.002). In-hospital mortality was similar between groups (OR 1.80, 95% CI 0.96-3.37). Only age and the use of inotropes or intra-aortic balloon pump were predictors of mortality. Also, no differences between groups were noted for successful PCI (OR 0.33, 95% CI 0.62-4.06), reinfarction (OR 0.77, 95% CI 0.15-3.90), or major bleeding (OR 1.68, 95% CI 0.75-3.74). CONCLUSION: The use of GPIs in the context of MI with CS did not significantly impact in-hospital outcomes.

CARDIAC PAPILLARY FIBROELASTOMA: A CASE WITH UNPRECEDENTED SPREAD.

INTRODUCTION: Papillary fibroelastomas (PFE) are a rare primary cardiac neoplasm, out of which multifocal PFE constitute a small minority of cases. These benign masses are commonly found on valvular surfaces, particularly the aortic valve. CLINICAL CASE: We present a patient with a history of embolic stroke and intra-cardiac masses. Multimodal imaging revealed multiple nodules with extensive intra-cardiac distribution. All nodules were successfully removed without valve dysfunction. CONCLUSION: This is a unique case of multiple PFE involving intracardiac cavities as well as all valvular structures.

Aortic valve intervention for aortic stenosis and cardiac amyloidosis: a systematic review and meta-analysis.

Aortic stenosis with cardiac amyloidosis (CA-AS) is common in the elderly. We provide an overview and a meta-analysis of outcomes after aortic valve (AV) intervention. The primary end point was all-cause mortality. Weighted pooled analysis showed a non-significant higher risk of death in CA-AS patients following surgical or transcatheter AV replacement. After transcatheter AV replacement, the risk of death in CA-AS patients was comparable to that associated with aortic stenosis alone (risk ratio: 1.23; 95% CI: 0.77-1.96; p = 0.39; I2 = 0%). An AV intervention is possibly not futile in CA-AS and should not be denied to patients with this condition.

Dual presentation of aortic stenosis (AS) and cardiac amyloidosis (CA) is common in the elderly. Patients with CA-AS face a dismal prognosis. Clinical outcomes after an aortic valve intervention are conflicting. Our data showed that there is no increased risk of death in CA-AS patients compared with patients with only AS after an aortic valve replacement. In particular, our analysis unveils that following less invasive percutaneous aortic valve replacement, rates of death of patients with concomitant CA were not significantly different from those in patients who had AS without CA. Based on this data, an aortic valve substitution procedure should not be withheld in patients with CA.

3D printing for left atrial appendage closure: A meta-analysis and systematic review.

BACKGROUND: Three-dimensional printing (3D) has emerged as an alternative to imaging to guide left atrial appendage closure (LAAC) device sizing. AIMS: We assessed the usefulness of 3D printing compared to a standard imaging-only approach for LAAC. METHODS: We identified studies comparing an imaging-only with a 3D printing approach in LAAC. A fixed-effects meta-analysis was performed targeting a co-primary endpoint of disagreement in device sizing and leaks. RESULTS: Eight studies that assigned 283 participants to an imaging-only approach and 3D printing approach (145 patients) were included. 3D printing significantly reduced the risk of the co-primary endpoint (risk raio (RR) = 0.19; 95% confidence interval (CI) 0.09-0.37), with consistency across the studies (I2 = 0%). Individually, both device size disagreements [RR 0.13 (95% CI 0.06-0.29), P < 0.001] and leaks [RR 0.24 (95% CI 0.09-0.64) P = 0.004] were reduced under a 3D printing modeling strategy. CONCLUSION: Compared with an imaging-only strategy, 3D printing is associated with reduction in device size disagreements and leaks.

Computed tomography coronary angiography as the noninvasive in stable coronary artery disease? Long-term outcomes meta-analysis.

Aim: To compare outcomes of coronary computed tomography angiography (CCTA) with that of functional testing (FT) in stable coronary artery disease. Methods: We searched PubMed, Embase, and Cochrane for randomized controlled trials (RCTs). A random-effects meta-analysis targeting all-cause death and nonfatal acute coronary syndromes was performed. Results: Eight RCTs enrolling 29,579 patients were included. Pooled relative risk (RR) for the primary end point was similar between CCTA and FT (RR = 0.97; 95% CI: 0.76-1.22). CCTA outperformed FT in nonfatal myocardial infarction (MI) (RR = 0.59; 95% CI: 0.41-0.83) and in downstream testing (OR: 0.47; 95% CI: 0.21-1.01). Conclusion: Updated data of stable coronary artery disease suggests that CCTA improved nonfatal MI and downstream testing.

Coronary heart disease (narrowed or blocked arteries) can be diagnosed either by a functional testing or an anatomic testing. In functional testing, we will see if there is some reduced blood flow in the heart. In anatomic testing, a computerized tomography coronary angiogram is performed, to see the presence of atherosclerotic plaque (cholesterol) and the degree of obstruction. In this review, we provide an aerial view of the latest evidence on the best approach to coronary artery disease diagnosis. Updated evidence shows that a computerized tomography coronary angiogram reduced the risk of myocardial infarction and the need of further testing after an initial approach.

Transbasilic Approach for Percutaneous Closure of an Atrial Septal Defect.

Atrial septal defect (ASD) closure is indicated in the presence of a significant left-to-right shunt. In the case of an interrupted inferior vena cava (IVC), the standard percutaneous approach can be troublesome. The authors report a case of a 55-year-old female patient with an ostium secundum ASD with a significant left-to-right shunt at rest (Qp/Qs, 1.6). The cardiac computed tomography scan showed an interrupted IVC above the renal veins. To our knowledge, this is the first case in the literature where the transbasilic peripheral vein approach for ASD closure was used.

Chronic kidney disease in acute coronary syndromes: real-world data of long-term outcomes.

Aim: Patients with chronic kidney disease (CKD) are at increased cardiovascular risk. Methods: Patients with acute coronary syndrome were retrospectively allocated to three groups (stage 3A, stage 3B or stage 4) based on the Kidney Disease Improving Global Outcomes classification formulas: the CKD Epidemiology Collaboration (CKD-EPI; N = 401) and the modification of diet in renal disease (n = 355). The primary end point was all-cause mortality (median follow-up time, 32 months [15-70]). Results: Study results showed decreased median survival was associated with poor renal function for both the CKD-EPI (78 vs 61 vs 40 months, p = 0.014) and modification of diet in renal disease groups (68 vs 57 vs 32 months, p = 0.006). After adjustment, age (OR: 1.07; 95% CI: 1.01-1.14) and pulmonary artery systolic pressure (OR: 1.08; 95% CI: 1.03-1.14), but not estimated glomerular filtration rate, were associated with decreased survival. Conclusion: Study results suggest that poor outcomes after an acute coronary syndrome were associated with comorbidities rather than estimated glomerular filtration rate level.

Lay abstract Patients with chronic kidney failure have an elevated risk of heart attack or death. We studied patients with kidney failure and concurrent heart attack for 32 months (median). Our results suggest that poorer renal function was associated with an increased risk of death. However, the most important factors associated with survival were patient age and pulmonary artery systolic pressure and not the particular kidney function. Therefore, in this group of patients, comorbidities appear to play a role as survival determinants.

Left Ventricular Thrombus Therapy With Direct Oral Anticoagulants Versus Vitamin K Antagonists: A Systematic Review and Meta-Analysis.

BACKGROUND: Current guidelines recommend vitamin K antagonists (VKAs) for left ventricular thrombus (LVT) resolution. Direct oral anticoagulants (DOACs) are increasingly evaluated as alternatives to the standard of care in anticoagulation. METHODS: We performed a systematic review and meta-analysis to assess the use of DOACs vs VKAs for LVT treatment. The occurrence of LVT resolution, systemic embolism (SE) or stroke, and bleeding events were compared during follow-up using random-effects analysis. RESULTS: The 5 included studies were all observational (a total of 828 patients). Of these, 284 patients (34%) were treated with DOACs, and 544 (66%) treated with VKAs. Thrombus resolution was similar for both methods (pooled odds ratio [OR], 0.91; 95% CI, 0.47-1.75; I2 = 63%; P = .78). The incidence of SE or stroke was also similar (pooled OR, 1.59; 95% CI, 0.85-2.97; I2 = 0%; P = .14). Clinically relevant bleeding incidence was similar for both groups (pooled OR, 0.66; 95% CI, 0.31-1.40; I2 = 0%; P = .28), although all bleeding events were less frequent in the DOAC group (pooled OR, 0.49; 95% CI, 0.26-0.90; I2 = 0%; P = .02). CONCLUSION: Our systematic review and meta-analysis suggests DOACs were as effective as VKAs for LVT resolution, with a similar risk of systemic embolism/stroke and clinically relevant bleeding. These results, obtained from observational studies, are not definitive and hence randomized controlled trials are needed. Nevertheless, our analysis identifies key experimental features required in future studies.

Síndrome de ALCAPA em uma Mulher Jovem / ALCAPA Syndrome in a Young Woman

Mulher de 18 anos com histórico de síncope, angina e palpitações há um ano. Uma indicação crucial era artéria coronária direita dilatada na ecocardiografia transtorácica. Os achados da tomografia computadorizada resultaram no diagnóstico da origem anômala da artéria coronariana esquerda proveniente da síndrome da artéria pulmonar.(AU)

Glycoprotein IIb/IIIa inhibitors for cardiogenic shock complicating acute myocardial infarction: a systematic review, meta-analysis, and meta-regression.

BACKGROUND: Cardiogenic shock complicates 5-10% of myocardial infarction (MI) cases. Data about the benefit of glycoprotein IIb/IIIa inhibitors (GPI) in these patients is sparse and conflicting. METHODS: We performed a systematic review, meta-analysis, and meta-regression of studies assessing the impact of GPI use in the setting of MI complicated cardiogenic shock on mortality, angiographic success, and bleeding events. We systematically searched for studies comparing GPI use as adjunctive treatment versus standard care in this setting. Random-effects meta-analysis and meta-regression were performed. RESULTS: Seven studies with a total of 1216 patients (GPI group, 720 patients; standard care group, 496 patients) were included. GPI were associated with a 45% relative reduction in the odds of death at 30 days (pooled OR 0.55; 95% CI 0.35-0.85; I2 = 57%; P = 0.007) and a 49% reduction in the odds of death at 1 year (pooled OR 0.51; 95% CI 0.32-0.82; I2 = 58%; P = 0.005). Reduction in short-term mortality seemed to be more important before 2000, as this benefit disappears if only the more recent studies are analyzed. GPI were associated with a 2-fold increase in the probability of achieving TIMI 3 flow (pooled OR, 2.05; 95% CI 1.37-3.05; I2 = 37%, P = 0.0004). Major bleeding events were not increased with GPI therapy (pooled OR, 1.0; 95% CI 0.55-1.83; I2 = 1%, P = 0.99). Meta-regression identified that patients not receiving an intra-aortic balloon pump seemed to benefit the most from GPI use (Z = - 1.57, P = 0.005). CONCLUSION: GPI therapy as an adjunct to standard treatment in cardiogenic shock was associated with better outcomes, including both short- and long-term survival, without increasing the risk of bleeding.

Valvular Disease Begets Valvular Disease.

In acute severe aortic regurgitation, an inversion of pressure gradient from the left ventricle to the left atrium causes the classical sign of end-diastolic mitral regurgitation. Here we present a case of mid-diastolic mitral regurgitation in a 51-year-old man with severe aortic regurgitation secondary to infective endocarditis. (Level of Difficulty: Beginner.).

A Spleen Complication After an Acute Myocardial Infarction.

We highlight the potential risk of combined antithrombotic therapy as a rare cause of spontaneous splenic hemorrhage. Conservative management is possible and reintroduction of the antithrombotic therapy is safe after the acute event. (Level of Difficulty: Beginner.).

Global longitudinal strain in chronic asymptomatic aortic regurgitation: systematic review.

Chronic aortic regurgitation (AR) patients typically remain asymptomatic for a long time. Left ventricular mechanics, namely global longitudinal strain (GLS), has been associated with outcomes in AR patients. The authors conducted a systematic review to summarize and appraise GLS impact on mortality, the need for aortic valve replacement (AVR) and disease progression in AR patients. A literature search was performed using these key terms 'aortic regurgitation' and 'longitudinal strain' looking at all randomized and nonrandomized studies conducted on chronic aortic regurgitation. The search yielded six observational studies published from 2011 and 2018 with a total of 1571 patients with moderate to severe chronic AR. Only two studies included all-cause mortality as their endpoint. The other studies looked at the association between GLS with AVR and disease progression. The mean follow-up period was 4.2 years. We noted a great variability of clinical, methodological and/or statistical origin. Thus, meta-analytic portion of our study was limited. Despite a relevant heterogeneity, an impaired GLS was associated with adverse cardiac outcomes. Left ventricular GLS may offer incremental value in risk stratification and decision-making.