Relationship between the type of atrial fibrillation and thromboembolic events

Background/Aim. Atrial fibrillation (AF) increases the risk for ischemic stroke and other thromboembolic (TE) events. Aim of the study was to examine the relationship between clinical types of atrial fibrillation (AF) and (TE) events. Methods. This longitudinal, observational study included patients with nonvalvular AF as main indication for in-hospital and/or outpatient treatment in the Cardiology Clinic, Clinical Center of Serbia during a period 1992-2007. The treatment of AF was based on the International Guidelines for diagnosis and treatment of AF, correspondent to given study period. Clinical types of AF were defined according to the latest ACC/AHA/ESC Guidelines for AF, from 2006. Diagnosis of central and systemic TE events during a follow-up was made exclusively by the neurologist and vascular surgeon. Results. During a follow-up of 9.9 ± 6 years, TE events were documented in 88/1 100 patients (8%). In the time of TE event 46/88 patients (52.3%) had permanent AF. The patients with permanent AF were at baseline significantly older and more frequently had underlying heart disease and diabetes mellitus. Cumulative TE risk during follow-up was similar for patients with paroxysmal and permanent AF, and significantly higher as compared to TE risk in patients with persistent AF. However, multivariate Cox proportional hazard regression analysis with independent variables clinical types of AF at baseline and in the time of TE event, clinical and echocardiographic characteristics and therapy for prevention of TE complications at baseline and at the time of TE event, did not reveal independent predictive value of clinical type of AF for the occurrence of TE events during a follow-up. Conclusion. TE risk in patients with AF does not depend on clinical type of AF. Treatment for prevention of TE events should be based on the presence of well recognized risk factors, and not on the clinical type of AF

Long COVID-19 syndrome: An overview

The Long COVID-19 syndrome has emerged as global epidemic, affecting individuals after an acute infection caused by the Severe acute respiratory syndrome coronavirus 2, impacting multiple organs, including the heart. The most common symptoms encompass fatigue and shortness of breath, which could persist for months after an acute COVID-19 infection. Numerous studies have researched the pathophysiology of Long COVID-19 syndrome, suggesting that local tissue damage and hyperinflation could be employed as possible mechanisms of Long COVID-19 syndrome. Many blood biomarkers (blood urea nitrogen, D-dimer, lymphopenia, troponin-1, interleukin-6, and CRP) and clinical risk factors (CRP female sex, a history of psychiatric disorders, and the presence of more than five symptoms during the first week of an acute illness) are shown to be associated with the development of Long COVID-19 syndrome. Currently, the evidence-based specific pharmacological treatments for the Long COVID-19 syndrome are lacking. Several studies have shown an association between antiviral drugs (such as nirmatrelvir, ensitrelvir, and molnupiravir) and vaccination against COVID-19 with a reduced risk of developing Long COVID-19 syndrome. This narrative review discusses the possible pathophysiology, risk factors, and treatments for Long COVID-19 syndrome with particular reference to the cardiovascular system

Results of radiofrequency ablation of atrial flutter using externally irrigated-tip catheters

Uvod: Pretkomorsko treperenje (atrijalna fibrilacija [AF] ) i pretkomorsko lepršanje (atrijalni flater [AFL] ) su srodne aritmije, koje dele isti elektrofiziološki supstrat. Godišnja incidenca AFL u opštoj populaciji iznosi 88 novih slučajeva na 100.000 odraslih osoba. Veći rizik od pojave AFL imaju muškarci, starije osobe, bolesnici sa srčanom insuficijencijom i hroničnom opstruktivnom bolešću pluća (HOBP). AFL ima veliki klinički značaj, jer može dovesti do tahikardiomiopatije, sistemskog tromboembolizma sa šlogom i redukcije kvaliteta života. Radiofrekventna kateterablacija (RFKA) kavotrikuspidnog istmusa (KTI), kao kritičnog supstrata aritmije, je efikasnija od antiaritmijske (AA) terapije u kliničkoj kontroli tipičnog AFL i stoga predstavlja prvu terapijsku opciju. Usled složene anatomije KTI procedura može biti pravi izazov. Hlađenjem vrha katetera tokom RFKA, tehnologija spoljne irigacije obezbeđuje stabilniju emisiju energije u tkivo uz kreiranje nekrotične lezije većeg volumena u poređenju sa konvencionalnom RFKA, te je omogućena efikasnija ablacija KTI. S druge strane, hlađenjem vrha katetera gubi se povratna informacija o realnoj temperaturi kontaktne površine katetera i tkiva te može doći do pregrevanja tkiva i proceduralnih komplikacija. Cilj: analiza (1) primarnog uspeha RFKA KTI upotrebom katetera sa spoljnom irigacijom vrha, (2) periproceduralnih komplikacija, i (3) dugoročnog kliničkog efekta procedure na pojavu AFL, AF, kontrolu srčane insuficijencije (SI), upotrebu AA lekova i simptomatski status. Metode: Analizirana je populacija od 248 konsekutivnih bolesnika (≥18 god., >40 kg), koji su podvrgnuti RFKA tipičnog AFL u Kliničkom centru Srbije u periodu od januara 2007.god do decembra 2013.god. uz upotrebu katetera sa spoljnom irigacijom. Svi bolesnici su imali tipičan AFL dokumentovan na EKG-u pre procedure. RFKA je vršena linearnim pristupom najpre centralnog a zatim (ako je neophodno) septalnog i/ili lateralnog KTI. Primarni cilj procedure bio je bidirekcioni blok u istmusu koji je definisan kao prisustvo minimalno 2 od 3 kriterijuma: (1) descendentna aktivaciona sekvenca na lateralnom zidu desne pretkomore pri stimulaciji iz koronarnog sinusa, (2) vremenski interval preko KTI >140 ms, (3) dvostruki signali na KTI >90 ms...Introduction: atrial fibrillation (AF) and atrial flutter (AFL) are related arrhythmias, sharing the same electrophysiological substrate. Annual AFL incidence rate is 88 new cases in 100.000 of adult persons in the general population. Males, older persons, patients with heart failure and chronic obstructive pulmonary disease (COPD) carry a higher risk of AFL occurrence. Occurrence of AFL can have significant clinical implications because it can lead to development of tachycardiomyopathy, systemic thrombo-embolism with ischemic stroke and quality of life reduction. Radiofrequency catheter ablation (RFCA) of cavotricuspid isthmus (CTI), which is the critical arrhythmia substrate, is more efficient than antiarrhythmic drugs (AAD) to clinically control AFL and therefore presents the first therapeutic option. Due to complex anatomy, CTI ablation can be real challenge. Cooling of ablation electrode during RFCA with external irrigation technology, provides more stable energy emission to the tissue with creation of necrotic lesion of larger volume, comparing to conventional RFCA. However, the cooling of the catheter tip loses a feedback on the real temperature of the contact surface and can lead to tissue overheating and procedural complications. Objectives: to determine (1) primary success rate of CTI RFCA using the externally irrigated-tip catheters, (2) periprocedural compliaction rate, (3) clinical effects of the procedure on long-term AFL and AF occurrence, heart failure (HF) control, AAD use and symptomatic status of the patients. Methods: Study population consisted of 248 consecutive patients (≥18 god., >40 kg) who underwent RFCA of typical AFL in Clinical Center of Serbia between January 2007 and December 2013, using externally irrigated-tip catheters. All patients had ECG confirmed typical AFL before the procedure. RFCA was performed by linear approach, initially at central, and thereafter, if necessary, at septal and/or lateral CTI segments. Primary end-point of the procedure was bidirectional isthmus block, defined as the presence of at least 2 of the following 3 criteria: (1) descendent activation sequence at the lateral right atrial wall during pacing from coronary sinus, (2) CTI time interval >140 ms, and (3) double potential at CTI >90 ms..

Results of radiofrequency ablation of atrial flutter using externally irrigated-tip catheters

Uvod: Pretkomorsko treperenje (atrijalna fibrilacija [AF] ) i pretkomorsko lepršanje (atrijalni flater [AFL] ) su srodne aritmije, koje dele isti elektrofiziološki supstrat. Godišnja incidenca AFL u opštoj populaciji iznosi 88 novih slučajeva na 100.000 odraslih osoba. Veći rizik od pojave AFL imaju muškarci, starije osobe, bolesnici sa srčanom insuficijencijom i hroničnom opstruktivnom bolešću pluća (HOBP). AFL ima veliki klinički značaj, jer može dovesti do tahikardiomiopatije, sistemskog tromboembolizma sa šlogom i redukcije kvaliteta života. Radiofrekventna kateterablacija (RFKA) kavotrikuspidnog istmusa (KTI), kao kritičnog supstrata aritmije, je efikasnija od antiaritmijske (AA) terapije u kliničkoj kontroli tipičnog AFL i stoga predstavlja prvu terapijsku opciju. Usled složene anatomije KTI procedura može biti pravi izazov. Hlađenjem vrha katetera tokom RFKA, tehnologija spoljne irigacije obezbeđuje stabilniju emisiju energije u tkivo uz kreiranje nekrotične lezije većeg volumena u poređenju sa konvencionalnom RFKA, te je omogućena efikasnija ablacija KTI. S druge strane, hlađenjem vrha katetera gubi se povratna informacija o realnoj temperaturi kontaktne površine katetera i tkiva te može doći do pregrevanja tkiva i proceduralnih komplikacija. Cilj: analiza (1) primarnog uspeha RFKA KTI upotrebom katetera sa spoljnom irigacijom vrha, (2) periproceduralnih komplikacija, i (3) dugoročnog kliničkog efekta procedure na pojavu AFL, AF, kontrolu srčane insuficijencije (SI), upotrebu AA lekova i simptomatski status. Metode: Analizirana je populacija od 248 konsekutivnih bolesnika (≥18 god., >40 kg), koji su podvrgnuti RFKA tipičnog AFL u Kliničkom centru Srbije u periodu od januara 2007.god do decembra 2013.god. uz upotrebu katetera sa spoljnom irigacijom. Svi bolesnici su imali tipičan AFL dokumentovan na EKG-u pre procedure. RFKA je vršena linearnim pristupom najpre centralnog a zatim (ako je neophodno) septalnog i/ili lateralnog KTI. Primarni cilj procedure bio je bidirekcioni blok u istmusu koji je definisan kao prisustvo minimalno 2 od 3 kriterijuma: (1) descendentna aktivaciona sekvenca na lateralnom zidu desne pretkomore pri stimulaciji iz koronarnog sinusa, (2) vremenski interval preko KTI >140 ms, (3) dvostruki signali na KTI >90 ms...Introduction: atrial fibrillation (AF) and atrial flutter (AFL) are related arrhythmias, sharing the same electrophysiological substrate. Annual AFL incidence rate is 88 new cases in 100.000 of adult persons in the general population. Males, older persons, patients with heart failure and chronic obstructive pulmonary disease (COPD) carry a higher risk of AFL occurrence. Occurrence of AFL can have significant clinical implications because it can lead to development of tachycardiomyopathy, systemic thrombo-embolism with ischemic stroke and quality of life reduction. Radiofrequency catheter ablation (RFCA) of cavotricuspid isthmus (CTI), which is the critical arrhythmia substrate, is more efficient than antiarrhythmic drugs (AAD) to clinically control AFL and therefore presents the first therapeutic option. Due to complex anatomy, CTI ablation can be real challenge. Cooling of ablation electrode during RFCA with external irrigation technology, provides more stable energy emission to the tissue with creation of necrotic lesion of larger volume, comparing to conventional RFCA. However, the cooling of the catheter tip loses a feedback on the real temperature of the contact surface and can lead to tissue overheating and procedural complications. Objectives: to determine (1) primary success rate of CTI RFCA using the externally irrigated-tip catheters, (2) periprocedural compliaction rate, (3) clinical effects of the procedure on long-term AFL and AF occurrence, heart failure (HF) control, AAD use and symptomatic status of the patients. Methods: Study population consisted of 248 consecutive patients (≥18 god., >40 kg) who underwent RFCA of typical AFL in Clinical Center of Serbia between January 2007 and December 2013, using externally irrigated-tip catheters. All patients had ECG confirmed typical AFL before the procedure. RFCA was performed by linear approach, initially at central, and thereafter, if necessary, at septal and/or lateral CTI segments. Primary end-point of the procedure was bidirectional isthmus block, defined as the presence of at least 2 of the following 3 criteria: (1) descendent activation sequence at the lateral right atrial wall during pacing from coronary sinus, (2) CTI time interval >140 ms, and (3) double potential at CTI >90 ms..

Results of radiofrequency ablation of atrial flutter using externally irrigated-tip catheters

Uvod: Pretkomorsko treperenje (atrijalna fibrilacija [AF] ) i pretkomorsko lepršanje (atrijalni flater [AFL] ) su srodne aritmije, koje dele isti elektrofiziološki supstrat. Godišnja incidenca AFL u opštoj populaciji iznosi 88 novih slučajeva na 100.000 odraslih osoba. Veći rizik od pojave AFL imaju muškarci, starije osobe, bolesnici sa srčanom insuficijencijom i hroničnom opstruktivnom bolešću pluća (HOBP). AFL ima veliki klinički značaj, jer može dovesti do tahikardiomiopatije, sistemskog tromboembolizma sa šlogom i redukcije kvaliteta života. Radiofrekventna kateterablacija (RFKA) kavotrikuspidnog istmusa (KTI), kao kritičnog supstrata aritmije, je efikasnija od antiaritmijske (AA) terapije u kliničkoj kontroli tipičnog AFL i stoga predstavlja prvu terapijsku opciju. Usled složene anatomije KTI procedura može biti pravi izazov. Hlađenjem vrha katetera tokom RFKA, tehnologija spoljne irigacije obezbeđuje stabilniju emisiju energije u tkivo uz kreiranje nekrotične lezije većeg volumena u poređenju sa konvencionalnom RFKA, te je omogućena efikasnija ablacija KTI. S druge strane, hlađenjem vrha katetera gubi se povratna informacija o realnoj temperaturi kontaktne površine katetera i tkiva te može doći do pregrevanja tkiva i proceduralnih komplikacija. Cilj: analiza (1) primarnog uspeha RFKA KTI upotrebom katetera sa spoljnom irigacijom vrha, (2) periproceduralnih komplikacija, i (3) dugoročnog kliničkog efekta procedure na pojavu AFL, AF, kontrolu srčane insuficijencije (SI), upotrebu AA lekova i simptomatski status. Metode: Analizirana je populacija od 248 konsekutivnih bolesnika (≥18 god., >40 kg), koji su podvrgnuti RFKA tipičnog AFL u Kliničkom centru Srbije u periodu od januara 2007.god do decembra 2013.god. uz upotrebu katetera sa spoljnom irigacijom. Svi bolesnici su imali tipičan AFL dokumentovan na EKG-u pre procedure. RFKA je vršena linearnim pristupom najpre centralnog a zatim (ako je neophodno) septalnog i/ili lateralnog KTI. Primarni cilj procedure bio je bidirekcioni blok u istmusu koji je definisan kao prisustvo minimalno 2 od 3 kriterijuma: (1) descendentna aktivaciona sekvenca na lateralnom zidu desne pretkomore pri stimulaciji iz koronarnog sinusa, (2) vremenski interval preko KTI >140 ms, (3) dvostruki signali na KTI >90 ms...Introduction: atrial fibrillation (AF) and atrial flutter (AFL) are related arrhythmias, sharing the same electrophysiological substrate. Annual AFL incidence rate is 88 new cases in 100.000 of adult persons in the general population. Males, older persons, patients with heart failure and chronic obstructive pulmonary disease (COPD) carry a higher risk of AFL occurrence. Occurrence of AFL can have significant clinical implications because it can lead to development of tachycardiomyopathy, systemic thrombo-embolism with ischemic stroke and quality of life reduction. Radiofrequency catheter ablation (RFCA) of cavotricuspid isthmus (CTI), which is the critical arrhythmia substrate, is more efficient than antiarrhythmic drugs (AAD) to clinically control AFL and therefore presents the first therapeutic option. Due to complex anatomy, CTI ablation can be real challenge. Cooling of ablation electrode during RFCA with external irrigation technology, provides more stable energy emission to the tissue with creation of necrotic lesion of larger volume, comparing to conventional RFCA. However, the cooling of the catheter tip loses a feedback on the real temperature of the contact surface and can lead to tissue overheating and procedural complications. Objectives: to determine (1) primary success rate of CTI RFCA using the externally irrigated-tip catheters, (2) periprocedural compliaction rate, (3) clinical effects of the procedure on long-term AFL and AF occurrence, heart failure (HF) control, AAD use and symptomatic status of the patients. Methods: Study population consisted of 248 consecutive patients (≥18 god., >40 kg) who underwent RFCA of typical AFL in Clinical Center of Serbia between January 2007 and December 2013, using externally irrigated-tip catheters. All patients had ECG confirmed typical AFL before the procedure. RFCA was performed by linear approach, initially at central, and thereafter, if necessary, at septal and/or lateral CTI segments. Primary end-point of the procedure was bidirectional isthmus block, defined as the presence of at least 2 of the following 3 criteria: (1) descendent activation sequence at the lateral right atrial wall during pacing from coronary sinus, (2) CTI time interval >140 ms, and (3) double potential at CTI >90 ms..

The occurrence of new arrhythmias after catheter-ablation of accessory pathway: Delayed arrhythmic side-effect of curative radiofrequency lesion?

Introduction. New arrhythmias (NA) may appear late after accessory pathway (AP) ablation, but their relation to curative radiofrequency (RF) lesion is unknown. Objective. The aim of this study was to determine the prevalence and predictors for NA occurrence after AP ablation and to investigate pro-arrhythmic effect of RF. Methods. Total of 124 patients (88 males, mean age 43±14 years) with Wolff-Parkinson-White syndrome and single AP have been followed after successful RF ablation. Post-ablation finding of arrhythmia, not recorded before the procedure, was considered a NA. The origin of NA was assessed by analysis of P-wave and/or QRS-complex morphology, and, thereafter, it was compared with locations of previously ablated APs. Results. Over the follow-up of 4.3±3.9 years, NA was registered in 20 patients (16%). The prevalence of specific NAs was as follows: atrioventricular (AV) block 0.8%, atrial premature beats 1.6%, atrial fibrillation 5.4%, atrial flutter 0.8%, sinus tachycardia 4.8%, ventricular premature beats (VPBs) 7.3%. Multivariate Cox-regression analysis identified (1) pre-ablation history of pathway-mediated tachyarrhythmias >10 years (HR=3.54, p=0.016) and (2) septal AP location (HR=4.25, p=0.003), as the independent predictors for NA occurrence. In four NA cases (two cases of septal VPBs, one of typical AFL and one of AV-block) presumed NA origin was identified in the vicinity of previous ablation target. Conclusion. NAs were found in 16% of patients after AP elimination. In few of these cases, late on-site arrhythmic effect of initially curative RF lesion might be possible. While earlier intervention could prevent NA occurrence, closer follow-up is advised after ablation of septal AP

Risk factor modification for the primary and secondary prevention of atrial fibrillation. Part 2

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with increased risk of death, stroke, and heart failure. Prevalence and incidence of AF are rising due to better overall medical treatment, longer survival, and increasing incidence of cardiometabolic and lifestyle risk factors. Treatment of AF and AF‑related complications significantly increases healthcare costs. In addition, the use of conventional rhythm control strategies (including, antiarrhythmic drugs and catheter ablation) is associated with limited efficacy for sinus rhythm maintenance and serious adverse effects. Aggressive cardiometabolic risk factor management may prevent incident as well as recurrent AF, improve overall health, and reduce mortality. Therefore, modifiable risk factor management became one of the 3 treatment pillars in AF management along with anticoagulation as well as conventional rate and rhythm control strategies. The second part of this review systematically discusses the association between AF and potentially modifiable risk factors for AF, such as obesity, obstructive sleep apnea, alcohol consumption, and dyslipidemia. We also provide practical guidelines for the risk factor management with respect to primary and secondary prevention of AF

Risk factor modification for the primary and secondary prevention of atrial fibrillation. Part 1

Modifiable risk factors, such as cardiometabolic and lifestyle risk factors, considerably contribute to (bi)atrial remodeling, finally resulting in clinical occurrence of atrial fibrillation (AF). Early identification and prompt intervention on these risk factors may delay further progression of atrial arrhythmia substrate and prevent the occurrence of new‑onset AF. Moreover, in patients with previous history of recurrent AF, aggressive risk factor management may improve efficacy of other rhythm control strategies, including antiarrhythmic drugs and catheter ablation in sinus rhythm maintenance. Finally, modification of risk factors improves overall health and reduces cardiovascular mortality and morbidity. The first part of this review evaluates the association between AF and the following risk factors: hypertension, diabetes mellitus, physical activity, and cigarette smoking. We systematically discuss the impact of risk factor modification on primary and secondary prevention of AF

A square root pattern of changes in heart rate variability during the first year after circumferential pulmonary vein isolation for paroxysmal atrial fibrillation and their relation with long‑term arrhythmia recurrence

BACKGROUND An incidental lesion of the parasympathetic ganglia during circumferential pulmonary vein isolation (CPVI) may affect heart rate variability (HRV). AIMS We studied the pattern of changes in HRV parameters and the relationship between the 1‑year HRV change following CPVI and the recurrence of atrial fibrillation (AF). METHODS A total of 100 consecutive patients undergoing CPVI for paroxysmal AF were enrolled (mean [SD] age, 56 [11.2] years; 61 men). We measured HRV on the day before and after CPVI, and then at 1 month as well as 3, 6, and 12 months after CPVI using 24‑hour Holter monitoring. RESULTS During the median follow‑up of 33 months, 38 patients experienced the late recurrence of AF (LRAF). Compared with the pre‑CPVI values, HRV was significantly attenuated on day 1 after CPVI in all patients. However, at 3 to 6 months after CPVI, all HRV parameters remained significantly decreased in LRAF‑free patients but not in those with LRAF. The multivariate Cox analysis showed that early AF recurrence within the blanking period (hazard ratio [HR], 4.87; 95% CI, 2.44–9.69; P <0.001) and a change in the standard deviation of normal‑to‑normal intervals (SDNN) observed 3 months after ablation (HR, 0.99; 95% CI, 0.98–1; P = 0.01) were associated with LRAF. The cumulative LRAF freedom after CPVI was greater in patients with an SDNN reduction of more than 25 ms reported 3 months after ablation than in those with a reduction of 25 ms or lower (log‑rank P = 0.004). CONCLUSIONS Sustained parasympathetic denervation during 12 months after CPVI was a marker of successful CPVI, whereas a 3‑month post‑CPVI SDNN reduction of 25 ms or lower predicted LRAF