Adenosine-guided pulmonary vein isolation versus conventional pulmonary vein isolation in patients undergoing atrial fibrillation ablation: An updated meta-analysis

BACKGROUND: Recurrent atrial fibrillation episodes following pulmonary vein isolation (PVI) are frequently due to reconnection of PVs. Adenosine can unmask dormant conduction, leading to additional ablation to improve AF-free survival. We performed a meta-analysis of the literature to assess the role of adenosine testing in patients undergoing atrial fibrillation (AF) ablation. METHODS: PubMed, EMBASE, and Cochrane databases were searched through until December 2015 for studies reporting on the role of adenosine guided-PVI versus conventional PVI in AF ablation. RESULTS: Eleven studies including 4099 patients undergoing AF ablation were identified to assess the impact of adenosine testing. Mean age of the population was 61 ± 3 years: 25% female, 70% with paroxysmal AF. Follow up period of 12.5 ± 5.1 months. A significant benefit was observed in the studies published before 2013 (OR = 1.75; 95%CI 1.32–2.33, p < 0.001, I2 = 11%), retrospective (OR = 2.05; 95%CI 1.47–2.86, p < 0.001, I2 = 0%) and single-centre studies (OR = 1.58; 95%CI 1.19–2.10, p = 0.002, I2 = 30%). However, analysis of studies published since 2013 (OR = 1.41; 95% CI 0.87–2.29, p = 0.17, I2 = 75%) does not support any benefit from an adenosine-guided strategy. Similar findings were observed by pooling prospective case-control (OR = 1.39; 95%CI 0.93–2.07, p = 0.11, I2 = 75%), and prospective randomized controlled studies (OR = 1.62; 95%CI 0.81–3.24, p = 0.17, I2 = 86%). Part of the observed high heterogeneity can be explained by parameters such as dormant PVs percentage, use of new technology, improvement of center/operator experience, patients' characteristics including gender, age, and AF type. CONCLUSIONS: Pooling of contemporary data from high quality prospective case–control & prospective randomized controlled studies fails to show the benefit of adenosine-guided strategy to improve AF ablation outcomes

Ankle-brachial index, vascular calcifications and mortality in dialysis patients

WOS:000299957700048 (Nº de Acesso Web of Science)“Prémio Científico ISCTE-IUL 2013”Background. The ankle-brachial index (ABI) is a noninvasive method to evaluate peripheral artery disease (PAD). ABI 1.3 is a false negative caused by noncompressible arteries. The aim of this study is to evaluate the association between ABI with vascular calcifications (VC) and with mortality, in haemodialysis (HD) patients. Methods. We studied 219 HD patients (60% male; 20% diabetic). At baseline, ABI was evaluated by a Doppler device. VCs were evaluated by two methods: the abdominal aorta calcification score (AACS) in a lateral plain X-ray of the abdominal aorta and the simple vascular calcification score (SVCS) in plain X-rays of the pelvis and hands. VC were also classified by their anatomical localization in main vessels (aorta and iliac-femoral axis) and in peripheral or distal vessels (pelvic, radial or digital). The cutoff values for the different VC scores in relation with ABI were determined by receiver operating characteristic curve analysis. Biochemical parameters were time averaged for the 6 months preceding ABI evaluation. Results. An ABI 1.3 or a normal ABI were found, respectively, in 90 (41%), in 42 (19%) and in 87 (40%) patients. AACS >= 6 and SVCS >3 were found, respectively, in 98 (45%) and 95 (43%) patients. The adjusted odds ratio (OR) for having an ABI = 6 and 4.5 (P = 2. The adjusted OR for having an ABI >1.3 was 4.2 (P = 0.003) for pelvic CS and 3.7 (P = 0.006) for hand CS >= 2. During an observational period of 28.9 months, all-cause and cardiovascular mortality occurred, respectively, in 50 (23%) and in 29 (13%) patients. Adjusting for age, diabetes, P levels, HD duration and cardiovascular disease at baseline, an ABI 1.3 (HR = 2.7, P = 0.038) were associated with all-cause mortality; an ABI 1.3 (HR = 5.1, P = 0.028) were associated with cardiovascular mortality. Conclusions. Both low and high ABI were independent predictors of all-cause and cardiovascular mortality. VC in main arteries were associated with an ABI 1.3. ABI is a simple and noninvasive method that allows the identification of high cardiovascular risk patients

New insertable cardiac monitors show high diagnostic yield and good safety profile in real-world clinical practice. results from the international prospective observational SMART Registry

Aims: Insertable cardiac monitors (ICMs) are indicated for long-term monitoring of unexplained syncope or palpitations, and for detection of bradycardia, ventricular tachycardia, and/or atrial fibrillation (AF). The aim of our study was to evaluate the safety and clinical value associated with a new generation ICM (Confirm Rx™, Abbott, Illinois, USA), featuring a new remote monitoring system based on smartphone patient applications. Methods and results: The SMART Registry is an international prospective observational study. The main endpoints were ICM safety (incidence of serious adverse device and procedure-related events (SADEs) at 1 month), ICM clinical value (incidence of device-detected true arrhythmias and of clinical diagnoses and interventions), and patient-reported experience measurements (PREMs). A total of 1400 subjects were enrolled. ICM indications included syncope (49.1%), AF (18.8%), unexplained palpitations (13.6%), risk of ventricular arrhythmia (6.6%), and cryptogenic stroke (6.0%). Freedom from SADEs at 1 month was 99.4% (95% Confidence Interval: 98.8-99.7%). In the 6-month monitoring period, the ICM detected true cardiac arrhythmias in 45.7% of patients and led to clinical interventions in a relevant proportion of patients; in particular, a pacemaker implant was performed after bradycardia detection in 8.9% of subjects who received an ICM for syncope and oral anticoagulation therapy was indicated after AF detection in 15.7% of subjects with cryptogenic stroke. PREMs showed that 78.2% of subjects were satisfied with the remote monitoring patient app. Conclusion: The evaluated ICM is associated with an excellent safety profile and high diagnostic yield. Patients reported positive experiences associated with the use of their smartphone for the device remote monitoring

Ablation Strategies for Different Types of Atrial Fibrillation in Europe: Results of the ESC-EORP EHRA Atrial Fibrillation Ablation Long-Term Registry

Aims: The ESC EORP EHRA Atrial Fibrillation (AF) Ablation Long-Term registry was designed to assess management and outcomes of AF catheter ablation procedures in Europe. To investigate the current ablation approaches and their outcomes for patients with paroxymal AF (PAF) and non-PAF in Europe. Methods and results: Data from index ablations were collected in 27 European countries at 104 centres in a prospective fashion. Pre-procedural, procedural, and 1-year follow-up data were captured on a web-based electronic case record form. Data on the ablation procedure were available for 3446 patients. Of these, 2513 patients and 933 patients underwent pulmonary vein isolation (PVI) or PVI plus (PVIplus) additional ablation, respectively. The ablation strategy was limited to PVI in 81% and 56% of patients in the PAF and non-PAF group, respectively (P < 0.001). In the non-PAF group, left atrial linear ablation and ablation of complex fragmented atrial electrograms were more commonly performed. Arrhythmias recurrence after PVI was 29% and 39% in the PAF and non-PAF group, respectively (P < 0.001) and 42% after PVIplus in both groups. Atrial fibrillation related hospital admissions were more common in the PVIplus group (20% vs. 14%). A very low procedural complication rate was observed. No relevant differences were observed with regard to repeat ablation (PVI 9% and PVIplus 11%). Conclusion: In patients with PAF and non-PAF, the ablation strategies of PVI and PVIplus led to similar arrhythmia-free survival rates after 1 year. A considerable hospital readmission rate was noted.info:eu-repo/semantics/publishedVersio

Catheter ablation of atrial fibrillation in patients with hypertrophic cardiomyopathy: a European observational multicentre study

AIMS: Atrial fibrillation (AF) is common in hypertrophic cardiomyopathy (HCM). Data on the efficacy of catheter ablation of AF in HCM patients are sparse. METHODS AND RESULTS: Observational multicentre study in 137 HCM patients (mean age 55.0 ± 13.4, 29.1% female; 225 ablation procedures). We investigated (i) the efficacy of catheter ablation for AF beyond the initial 12 months; (ii) the available risk scores, stratification schemes and genotype as potential predictors of arrhythmia relapse, and (iii) the impact of cryoballoon vs. radiofrequency in procedural outcomes. Mean follow-up was 43.8 ± 37.0 months. Recurrences after the initial 12-month period post-ablation were frequent, and 24 months after the index procedure, nearly all patients with persistent AF had relapsed, and only 40% of those with paroxysmal AF remained free from arrhythmia recurrence. The APPLE score demonstrated a modest discriminative capacity for AF relapse post-ablation (c-statistic 0.63, 95% CI 0.52-0.75; P = 0.022), while the risk stratification schemes for sudden death did not. On multivariable analysis, left atrium diameter and LV apical aneurysm were independent predictors of recurrence. Fifty-eight patients were genotyped; arrhythmia-free survival was similar among subjects with different gene mutations. Rate of procedural complications was high (9.3%), although reducing over time. Outcome for cryoballoon and radiofrequency ablation was comparable. CONCLUSION: Very late AF relapses post-ablation is common in HCM patients, especially in those with persistent AF. Left atrium size, LV apical aneurysm, and the APPLE score might contribute to identify subjects at higher risk of arrhythmia recurrence. First-time cryoballoon is comparable with radiofrequency ablation

Vitamin D, and Kidney Disease

Mineral metabolism abnormalities, such as low 1,25-dihydroxyvitamin D (1,25(OH)2D) and elevated parathyroid hormone (PTH), are common at even higher glomerular filtration rate than previously described. Levels of 25-hydroxyvitamin D (25(OH)D) show an inverse correlation with those of intact PTH and phosphorus. Studies of the general population found much higher all-cause and cardiovascular (CV) mortality for patients with lower levels of vitamin D; this finding suggests that low 25(OH)D level is a risk factor and predictive of CV events in patients without chronic kidney disease (CKD). 25(OH)D/1,25(OH)2D becomes deficient with progression of CKD. Additionally, studies of dialysis patients have found an association of vitamin D deficiency with increased mortality. Restoration of the physiology of vitamin D receptor activation should be essential therapy for CKD patients

Impact of Type-2 Diabetes Mellitus on the Outcomes of Catheter Ablation of Atrial Fibrillation (European observational multicentre study)

Type-2 diabetes mellitus (DM) is associated with an increased risk of atrial fibrillation (AF). It is unclear whether DM is a risk factor for arrhythmia recurrence following catheter ablation of AF. We performed a nonrandomised, observational study in 7 high-volume European centres. A total of 2,504 patients who underwent catheter ablation of AF were included, and procedural outcomes were compared among patients with or without DM. Patients with DM (234) accounted for 9.3% of the sample, and were significantly older, had a higher BMI and suffered more frequently from persistent AF. Arrhythmia relapses at 12 months after AF ablation occurred more frequently in the DM group (32.0% vs 25.3%, p = 0.031). After adjusting for type of AF (i.e., paroxysmal vs persistent), during a median follow-up of 17 ± 16 months, atrial arrhythmia free-survival was lower in the diabetics with persistent AF (log-rank p = 0.003), and comparable for paroxysmal AF (log-rank p = 0.554). These results were confirmed in a propensity-matched analysis, and DM was also an independent predictor of AF recurrence on the multivariate analysis (hazard ratio 1.39; 95% confidence interval 95%1.07 to 1.88; p = 0.016). There was no significant difference in the rate of periprocedural complications among DM and non-DM patients (3.8% vs 6.3%, p = 0.128). Efficacy and safety of cryoballoon ablation were comparable to radiofrequency ablation in both DM and no-DM groups. In conclusion, catheter ablation of AF appears to be safe in patients with DM. However, DM is associated with higher rate of atrial arrhythmia relapse, particularly for patients with persistent AF