ADVANCED INTERATRIAL BLOCK PREDICTS INEFFECTIVE CARDIOVERSION OF ATRIAL FIBRILLATION

Aims: Rhythm control using electrical cardioversion (CV) is a common treatment strategy for patients with symptomatic atrial fibrillation (AF). To guide clinical decision making, we sought to assess if electrocardiographic interatrial blocks could predict CV failure or AF recurrence as the phenomenon is strongly associated with atrial arrhythmias. Methods: This study included 715 patients who underwent a CV for persistent AF lasting >48h. P-wave duration and morphology were analysed in post-procedure or the most recent sinus rhythm electrocardiograms and compared with rates of CV failure and AF recurrence within 30 days after CV as well as their combination (ineffective CV). Results: CV was unsuccessful in 63 out of 715 patients (8.8%) and AF recurred in 209 out of 652 (29.2%) patients within 30 days after CV. Overall, 272 (38.0%) CVs turned out ineffective. Advanced interatrial block (AIAB) defined as P-wave duration ≥120ms and biphasic morphology in inferior leads (II, III and aVF) was diagnosed in 72 (10.1%) cases. AIAB was an independent predictor for CV failure (OR 4.51, 95%CI 1.76-11.56, p=0.002), AF recurrence (OR 2.93, 95%CI 1.43-5.99, p=0.003) and ineffective CV (OR 3.87, 95%CI 2.04-7.36, p<0.001). Conclusion: AIAB predicted CV failure, AF recurrence as well as their composite. This study presents an easy electrocardiographic tool for identification of patients with persistent AF who might not benefit from an elective CV in the future.Kohtauksellinen eteisvärinä koetaan usein epämiellyttävänä sydämen tykyttelynä, heikentyneenä rasituksen sietona tai yleisvoinnin laskuna. Eteisten kaoottinen syke ja epätäydellinen supistuminen yhdessä epätasaisen kammiovasteen kanssa voivat aiheuttaa oireilua verenkierron heikkenemisen myötä. Oireet voidaan poistaa palauttamalla normaali sinusrytmi esimerkiksi antamalla synkronoitu isku defibrillaattorilla. Sähköinen rytminsiirto on kuitenkin tehoton noin kolmanneksessa tapauksista ja lisäksi toimenpiteeseen liittyy kohonnut tromboembolian riski. Toistaiseksi toimenpiteestä hyötyvien potilaiden tunnistaminen on ollut puutteellista. Tutkimus käsittelee eteisvärinäpotilaan sydänfilmin roolia rytminsiirron onnistumisen ja siihen liittyvien komplikaatioiden ennakoimisessa. Erityisenä kiinnostuksen kohteena oli eteisten välinen johtumishäiriö (interatrial block), joka nähdään alaraajakytkennöissä pidentyneenä ja kaksivaiheisena eteisaktivaationa. Rekisteritutkimuksen aineisto koostui Turun alueella elektiivisesti rytminsiirrolla hoidetuista potilaista, joilla oli saatavilla sähköisesti arkistoitu sinusrytmin aikainen sydänfilmi. Esitietojen lisäksi aineistoon kirjattiin toimenpiteen onnistuminen ja kuukauden seurannan aikana tapahtuneet komplikaatiot sekä eteisvärinän uusiutuminen. Tutkimuksen tulokset viittaavat eteisten välisen katkoksen olevan merkittävä riskitekijä rytminsiirron epäonnistumiselle ja eteisvärinän nopealle uusiutumiselle. Tällä potilasryhmällä jopa kaksi kolmesta toimenpiteestä oli tehoton, kun verrokeilla vain kolmannes jäi ilman toimenpiteen hyötyä. Komplikaatioriskissä ei ollut ryhmien välistä eroa. Löydösten merkittävyyttä lisää myös se, että aineiston perusteella eteisten välinen katkos vaikuttaa liittyvän vahvasti eteisvärinään. Tutkimuksessa katkos löytyi joka kymmenenneltä potilaalta, kun väestössä vallitsevuus on vain noin 1%. Tulosten perusteella sydänfilmiä voitaisiin käyttää osana eteisvärinäpotilaan yksilöllistä hoidonsuunnittelua

Advanced interatrial block predicts ineffective cardioversion of atrial fibrillation: a FinCV2 cohort study

Aims: Rhythm control using electrical cardioversion (CV) is a common treatment strategy for patients with symptomatic atrial fibrillation (AF). To guide clinical decision making, we sought to assess if electrocardiographic interatrial blocks could predict CV failure or AF recurrence as the phenomenon is strongly associated with atrial arrhythmias.Methods: This study included 715 patients who underwent a CV for persistent AF lasting >48 h. P-wave duration and morphology were analyzed in post-procedure or the most recent sinus rhythm electrocardiograms and compared with rates of CV failure and AF recurrence within 30 days after CV as well as their combination (ineffective CV).Results: CV was unsuccessful in 63 out of 715 patients (8.8%) and AF recurred in 209 out of 652 (29.2%) patients within 30 days after CV. Overall, 272 (38.0%) CVs turned out ineffective. Advanced interatrial block (AIAB) defined as P-wave duration >= 120 ms and biphasic morphology in inferior leads (II, III and aVF) was diagnosed in 72 (10.1%) cases. AIAB was an independent predictor for CV failure (OR 4.51, 95%CI 1.76-11.56, p = .002), AF recurrence (OR 2.93, 95%CI 1.43-5.99, p = .003) and ineffective CV (OR 3.87, 95%CI 2.04-7.36, p Conclusion: AIAB predicted CV failure, AF recurrence as well as their composite. This study presents an easy electrocardiographic tool for the identification of patients with persistent AF who might not benefit from an elective CV in the future. KEY MESSAGESInteratrial blocks are very common in patients with atrial fibrillation.Advanced interatrial block predicts ineffective cardioversion.</div

Fibrillatory wave amplitude and thromboembolic risk in non-anticoagulated patients with atrial fibrillation

The benefit of oral anticoagulation in atrial fibrillation (AF) is well established for patients at elevated stroke risk, but less clear for those at intermediate risk. We investigated whether analysis of electrocardiogram (ECG) derived fibrillatory waves (F-waves) could help identify patients at risk for stroke and systemic embolism (SSE). The Finnish Cardioversion (FinCV) study included patients not on permanent anticoagulation therapy who underwent cardioversion for an acute AF episode. We identified 739 individuals with a valid ECG and complete follow-up data. The maximum amplitudes of the F-waves in leads II and V1 were manually measured from the pre-procedure ECG. Patients were categorized into fine and coarse F-wave groups. The optimal lead and amplitude threshold for grouping were found in an events per person-years analysis. SSE were identified from the patient medical records until either anticoagulation was prescribed, AF was deemed chronic, the patient had deceased, or the end of follow-up. Overall 37 (5.0%) patients suffered SSE during the median follow-up time of 5.4 years (1.9–10.8). Measured from lead V1 the SSE rates per 100 person-years were 1.5 and 0.7 in fine and coarse F-wave groups, respectively. Fine F-waves were observed in 112 (15.2%). Baseline characteristics were similar between the groups. Fine F-wave predicted SSE in a competing risk analysis (SHR 2.34, 95%CI 1.12–4.87, p = .023). Analyses from lead II did not provide significant results. Electrocardiographic F-wave amplitude may provide additional information on stroke risk in patients with paroxysmal AF and borderline indications or contraindications for anticoagulation.</p

Risk of fluid accumulation after cardiac surgeryCentral MessagePerspective

Objective: Patients undergoing heart surgery are at high risk of postoperative fluid accumulation due to long procedures and cardiopulmonary bypass. In the present study, we sought to investigate the prevalence of postoperative fluid accumulation and its relation to adverse events in patients undergoing cardiac surgery. Methods: CAREBANK is prospective, single-center cohort study focusing on the adverse events after cardiac surgery. The study population was divided into 2 groups based on 5% postoperative weight gain. All the in-hospital adverse events are registered on the database. The end points of the present study were length of hospital stay, length of intensive care unit stay, occurrence of new-onset atrial fibrillation after hospital major bleeding episodes major cardiac events, cerebrovascular events, and death. Three-month and 1-year follow-up data also include all major adverse events. Results: Altogether 1001 adult cardiac surgery patients were enrolled. The most frequent operations were coronary artery bypass grafting (56.3%). Five hundred fifty-four out of 939 (59.0%) patients had ≥5% weight gain during index hospitalization. Patients with a weight gain ≥5% were more likely to be women, have lower body mass index, had heart failure, and more often had preoperative atrial fibrillation. In-hospital period fluid accumulation was associated with reoperation due bleeding and longer total hospital stay. At 3 months' follow-up, weight gain 5% or more was associated with increased occurrence of new-onset atrial fibrillation, this was not reflected in the occurrence of strokes, transient ischemic attacks, or myocardial infarctions. Conclusions: Postoperative fluid excess is associated with adverse outcomes in cardiac surgery. Women, low-weight patients, and patients with cardiac failure or atrial fibrillation are prone to perioperative fluid accumulation