Atrial fibrillation in high-risk patients

La fibrillation auriculaire (FA) est la plus fréquente des arythmies cardiaques. La FA est associée à un risque accru d’accident vasculaire cérébral, d’insuffisance cardiaque et de mortalité, constituant un problème de santé publique majeur. L’avènement de nouvelles technologies permettant une surveillance électrocardiographique a démontré une haute prévalence de FA subclinique ou silencieuse chez les patients âgés à haut risque. Récemment, plusieurs efforts et essais thérapeutiques ont été dirigés vers une identification et un traitement plus précoces de la FA chez ces patients. L’anticoagulation orale a bien prouvé son efficacité dans la prévention thromboembolique chez les patients qui présentent un haut risque thromboembolique, mais au prix d’une augmentation significative des événements hémorragiques, un risque qui s’élève régulièrement chez les patients âgés et avec une comorbidité importante. Au cours des dernières années, des nouvelles alternatives non-pharmacologiques dans la prévention thromboembolique ont été développées. La fermeture percutanée de l’auricule gauche, site de formation de la majorité (~90%) des thrombus, est progressivement devenue une alternative valable à l’anticoagulation chez des patients avec FA non valvulaire à haute risque hémorragique. L’expérience des opérateurs et les innovations technologiques ont permis une amélioration remarquable des résultats en ce qui concerne la sécurité et l’efficacité. Cependant, quelques questions restent sans réponse. Les préoccupations les plus débattues suite à la fermeture de l’auricule gauche sont la prise en charge de l’anticoagulation postprocédure et la prévention/gestion de la thrombose de dispositif. Les objectifs de ce travail de recherche sont : (i) évaluer la charge arythmique silencieuse chez des patients à haut risque à l’aide de l’utilisation de nouveaux systèmes d’enregistrement électrocardiographique prolongé, et (ii) analyser l'impact hémodynamique et thrombogénique de la fermeture percutanée de l'auricule gauche avec les dispositifs actuels et émergents.Atrial fibrillation (AF) is the most common cardiac arrhythmia. AF is associated with an increased risk of stroke, heart failure and mortality, posing a major public health problem. The advent of new technologies for continuous electrocardiographic monitoring has demonstrated a high incidence of subclinical or silent AF in elderly high-risk patients. Recently, several therapeutic efforts and studies have been directed towards earlier identification and treatment of AF in these patients. Oral anticoagulation has proven to be effective in preventing thromboembolism in patients at high thromboembolic risk, albeit at the expense of a significant increase in hemorrhagic events; a risk that increases steadily in elderly patients with high comorbidity burden. In recent years, novel non-pharmacological alternatives have been developed for thromboembolic prevention. Percutaneous left atrial appendage (LAA) closure, site of origin of the vast majority (~ 90%) of thrombi, has progressively become a valid alternative to anticoagulation in patients with non-valvular AF at high bleeding risk. Increasing operators' experience and technological innovations have led to remarkable improvements in the safety and efficacy of the procedure. However, some issues remain unanswered or controversial. Two of the most debated concerns are post-procedural antithrombotic management and device-related thrombosis (DRT) following LAA closure. The aims of the present research study are: (i) to evaluate the silent arrhythmic burden in high-risk patients using novel prolonged continuous electrocardiographic monitoring systems, and (ii) to assess the hemodynamic and thrombogenic impact of percutaneous LAA closure using current and emerging devices

Arrhythmic Burden as Determined by Ambulatory Continuous Cardiac Monitoring in Patients With New-Onset Persistent Left Bundle Branch Block Following Transcatheter Aortic Valve Replacement: The MARE Study.

The authors sought to determine: 1) the global arrhythmic burden; 2) the rate of arrhythmias leading to a treatment change; and 3) the incidence of high-degree atrioventricular block (HAVB) at 12-month follow-up in patients with new-onset persistent left bundle branch block (LBBB) following transcatheter aortic valve replacement (TAVR). Controversial data exist on the occurrence of significant arrhythmias in patients with LBBB post-TAVR. This was a multicenter prospective study including 103 consecutive patients with new-onset persistent LBBB post-TAVR with the balloon-expandable SAPIEN XT/3 valve (n = 53), or the self-expanding CoreValve/Evolut R system (n = 50). An implantable cardiac monitor (Reveal XT, Reveal Linq) was implanted at 4 (3 to 6) days post-TAVR, and patients had continuous electrocardiogram monitoring for 12 months. All arrhythmic events were adjudicated in a central electrocardiography core lab. Primary endpoints were the incidence of arrhythmias leading to a treatment change, and the incidence of HAVB at 12-month follow-up. A total of 1,553 new arrhythmic events were detected in 44 patients (1,443 episodes of tachyarrhythmia in 26 patients [atrial fibrillation/flutter/atrial tachycardia: 1,427, ventricular tachycardia 16]; 110 episodes of bradyarrhythmia in 21 patients [HAVB 54, severe bradycardia 56]). All arrhythmic events were silent in 34 patients (77%), the arrhythmic event led to a treatment change in 19 patients (18%), and 11 patients (11%) required pacemaker or implantable cardioverter-defibrillator implantation (due to HAVB, severe bradycardia, or ventricular tachycardia episodes in 9, 1, and 1 patient, respectively). A total of 12 patients died at 1-year follow-up, 1 from sudden death. A high incidence of arrhythmic events was observed at 1-year follow-up in close to one-half of the patients with LBBB post-TAVR. Significant bradyarrhythmias occurred in one-fifth of the patients, and PPM was required in nearly one-half of them. These data support the use of a cardiac monitoring device for close follow-up and expediting the initiation of treatment in this challenging group of patients. (Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEft Bundle Branch Block After Transcatheter Aortic Valve Implantation [MARE study]: NCT02153307)

Acute Coronary Syndrome Following Transcatheter Aortic Valve Replacement.

Scarce data exist on coronary events following transcatheter aortic valve replacement (TAVR), and no study has determined the factors associated with poorer outcomes in this setting. This study sought to determine the clinical characteristics, outcomes, and prognostic factors of acute coronary syndrome (ACS) events following TAVR. Multicenter cohort study including a total of 270 patients presenting an ACS after a median time of 12 (interquartile range, 5-17) months post-TAVR. Post-ACS death, myocardial infarction, stroke, and overall major adverse cardiovascular or cerebrovascular events were recorded. The ACS clinical presentation consisted of non-ST-segment-elevation myocardial infarction (STEMI) type 2 (31.9%), non-STEMI type 1 (31.5%), unstable angina (28.5%), and STEMI (8.1%). An invasive strategy was used in 163 patients (60.4%), and a percutaneous coronary intervention was performed in 97 patients (35.9%). Coronary access issues were observed in 2.5% and 2.1% of coronary angiography and percutaneous coronary intervention procedures, respectively. The in-hospital mortality rate was 10.0%, and at a median follow-up of 17 (interquartile range, 5-32) months, the rates of death, stroke, myocardial infarction, and major adverse cardiovascular or cerebrovascular events were 43.0%, 4.1%, 15.2%, and 52.6%, respectively. By multivariable analysis, revascularization at ACS time was associated with a reduction of the risk of all-cause death (hazard ratio, 0.54 [95% CI, 0.36-0.81] P=0.003), whereas STEMI increased the risk of all-cause death (hazard ratio, 2.06 [95% CI, 1.05-4.03] P=0.036) and major adverse cardiovascular or cerebrovascular events (hazard ratio, 1.97 [95% CI, 1.08-3.57] P=0.026). ACS events in TAVR recipients exhibited specific characteristics (ACS presentation, low use of invasive procedures, coronary access issues) and were associated with a poor prognosis, with a very high in-hospital and late death rate. STEMI and the lack of coronary revascularization determined an increased risk. These results should inform future studies to improve both the prevention and management of ACS post-TAVR

Transcatheter Mitral Repair for Functional Mitral Regurgitation According to Left Ventricular Function: A Real-Life Propensity-Score Matched Study

Background: Transcatheter mitral valve repair (TMVR) could improve survival in functional mitral regurgitation (FMR), but it is necessary to consider the influence of left ventricular ejection fraction (LVEF). Therefore, we compare the outcomes after TMVR with Mitraclip® between two groups according to LVEF. Methods: In an observational registry study, we compared the outcomes in patients with FMR who underwent TMVR with and without LVEF <30%. The primary endpoint was the combined one-year all-cause mortality and unplanned hospital readmissions due to HF. The secondary end-points were New York Heart Association (NYHA) functional class and mitral regurgitation (MR) severity. Propensity-score matching was used to create two groups with the same baseline characteristics, except for baseline LVEF. Results: Among 535 FMR eligible patients, 144 patients with LVEF <30% (group 1) and 144 with LVEF >30% (group 2) had similar propensity scores and were included in the analyses. The primary study endpoint was significantlly higher in group 1 (33.3% vs. 9.4%, p = 0.002). There was a maintained improvement in secondary endpoints without significant differences among groups. Conclusion: FMR patients with LVEF <30% treated with MitraClip® had higher mortality and readmissions than patients with LVEF ≥30% treated with the same device. However, both groups improved the NYHA functional class and MR severity

ST-Segment Elevation Myocardial Infarction Following Transcatheter Aortic Valve Replacement

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