Seizure-Like Activities during Head-Up Tilt Test-Induced Syncope

Purpose: Some patients with neurally mediated reflex syncope may be misdiagnosed as epilepsy because myoclonic jerky movements are observed during syncope. The seizure-like activities during the head-up tilt test (HUT) have been rarely reported. The purpose of this study was to assess the characteristics of these seizure-like activities and evaluate whether there are differences in the clinical characteristics and hemodynamic parameters of patients with neurally mediated reflex syncope with and without seizure-like activities during HUT-induced syncope. Materials and Methods: The medical records of 1,383 consecutive patients with a positive HUT were retrospectively reviewed, and 226 patients were included in this study. Results: Of 226 patients, 13 (5.75%) showed seizure-like activities, with 5 of these (2.21%) having multifocal myoclonic jerky movements, 5 (2.21%) having focal seizurelike activity involving one extremity, and 3 (1.33%) having upward deviation of eye ball. Comparison of patients with and without seizure-like activities revealed no significant differences in terms of clinical variables and hemodynamic parameters during HUT. Conclusion: Seizure-like activities occurred occasionally during HUTinduced syncope in patients with neurally mediated reflex syncope. The seizure-like activities during HUT might not be related to the severity of the syncopal episodes or hemodynamic changes during HUT. Key Words: Neurally mediated reflex syncope, seizure-like activities, head-up tilt tes

Catheter ablation or medical therapy to delay progression of atrial fibrillation : The randomized controlled atrial fibrillation progression trial (ATTEST)

Funding Information: This work was supported by Biosense Webster, Inc. Publisher Copyright: © 2020 The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.Aims: Delay of progression from paroxysmal to persistent atrial fibrillation (AF) is an important measure of long-term success of AF treatment. However, published data on the impact of catheter ablation on AF progression are limited. This study evaluates whether radiofrequency (RF) catheter ablation delays the progression of AF compared with antiarrhythmic drug (AAD) treatment using current AF management guidelines. Methods: This prospective, randomized, controlled, two-arm, open-label trial was conducted at 29 hospitals and medical centres across 13 countries. Patients were randomized 1: 1 to RF ablation or AAD treatment. The primary endpoint was the rate of persistent AF/atrial tachycardia (AT) at 3 years. Results: After early study termination following slow enrolment, 255 (79%) of the planned 322 patients were enrolled (RF ablation, n = 128, AAD, n = 127); 36% of patients in the RF ablation group and 41% in the AAD group completed 3 years of follow-up. For the primary endpoint, the Kaplan-Meier estimate of the rate of persistent AF/AT at 3 years was significantly lower with RF ablation [2.4% (95% confidence interval (CI), 0.6-9.4%)] than with AAD therapy [17.5% (95% CI, 10.7-27.9%); one-sided P = 0.0009]. Patients ≥65 years were ∼4 times more likely to progress to persistent AF/AT than patients <65 years, suggesting RF ablation can delay disease progression [hazard ratio: 3.87 (95% CI, 0.88-17.00); P = 0.0727]. Primary adverse events were reported for eight patients in the RF ablation group. Conclusions: Radiofrequency ablation is superior to guideline-directed AAD therapy in delaying the progression from paroxysmal to persistent AF.publishersversionPeer reviewe

Left Ventricular Dysfunction in Outpatients with Frequent Ventricular Premature Complexes

Frequent ventricular premature complexes (VPCs) and VPC QRS duration are risk factors for left ventricular (LV) dysfunction. To determine which clinical characteristics and electrocardiographic features are associated with LV dysfunction (ejection fraction, We identified 412 consecutive outpatients (mean age, 54.7 ± 16.8 yr; 227 women [55.1%]) who were diagnosed with frequent VPCs and had no structural heart disease from January 2010 through December 2017. Available transthoracic echocardiograms and 24-hour Holter monitoring data were evaluated to correlate the occurrence of VPCs and symptoms. Typical VPC-related symptoms (palpitations or dropped beats) were observed in 251 patients (61.1%). Electrocardiograms revealed VPCs with a left bundle branch block–like morphology in 327 patients (79.5%) and VPCs with an inferior axis in 353 (85.8%). Twenty-six patients (6.3%) were diagnosed with VPC-related LV dysfunction. The mean VPC burden did not differ significantly by LV functional status (11.06% ± 10.13% [normal] vs 14.41% ± 13.30% [impaired]; P=0.211). Patients with impaired LV function were more often men (P=0.027), had no typical VPC-related symptoms (P=0.006), and had significantly longer VPC QRS durations (mean, 157 ms vs 139 ms; P \u3c0.01). Our findings suggest that male sex, absence of typical VPC-related symptoms, and a VPC QRS duration \u3e157 ms are associated with LV dysfunction in patients with frequent VPCs, findings that may be useful in predicting such dysfunction

Plasma transforming growth factor β1 as a biochemical marker to predict the persistence of atrial fibrillation after the surgical maze procedure

ObjectivesThe Cox maze procedure was developed as a surgical treatment for atrial fibrillation. However, atrial fibrillation recurs in some patients, and atrial remodeling in the form of fibrosis can lead to perpetuation of atrial fibrillation. To identify the predictor of the persistence of atrial fibrillation after the maze procedure using cryoablation, we evaluated the preoperative plasma transforming growth factor β1. We also examined the correlations between plasma transforming growth factor β1 levels and the degree of atrial fibrosis.MethodsPreoperative plasma transforming growth factor β1 levels were measured in 86 consecutive patients (age, 54 ± 12 years) who underwent both the open heart operation for valvular heart disease and the surgical maze procedure with cryoablation for persistent atrial fibrillation. We measured the degree of fibrosis from the tissue of the left atrium.ResultsAt 1 year's follow-up, 10 of 86 patients had persistent atrial fibrillation. Patients with persistent atrial fibrillation had higher preoperative plasma transforming growth factor β1 levels than the patients with sinus rhythm (0.44 ± 0.29 vs 0.32 ± 0.15 ng/mL, P = .03). Patients with persistent atrial fibrillation had higher mRNA expressions of collagen III and lower mRNA expressions of atrial natriuretic peptide than those with sinus rhythm, and the plasma transforming growth factor β1 levels correlated with the degree of fibrosis in the left atrium (r = 0.497, P = .022). Multiple logistic regression analysis revealed that plasma transforming growth factor β1 levels were independently associated with the postoperative persistence of atrial fibrillation at 1 year's follow-up.ConclusionsPreoperative plasma transforming growth factor β1 levels could be used to predict the persistence of atrial fibrillation at 1 year's follow-up after the surgical maze procedure by using cryoablation. Preoperative plasma transforming growth factor β1 levels were correlated with the degree of fibrosis in the left atria of patients with mitral valvular heart disease

Catheter ablation of atrial fibrillation in Korea: results from the Korean Heart Rhythm Society Ablation Registry for Atrial Fibrillation (KARA)

Background This study aims to investigate the current status of AF (atrial fibrillation) catheter ablation in Korea. Methods The patients who underwent AF catheter ablation from September 2017 to December 2019 were prospectively enrolled from 37 arrhythmia centers. Demographic data, procedural characteristics, the extent of catheter ablation, acute success of the ablation lesion set, rate and independent risk factor for recurrence of AF were analyzed. Results A total of 2402 AF patients [paroxysmal AF (PAF) 45.7%, persistent AF (PeAF) 43.1% and redo AF 11.2%] were included. Pulmonary vein isolation (PVI) was performed in 2378 patients (99%) and acute success rate was 97.9%. Additional non-PV ablation (NPVA) were performed in 1648 patients (68.6%). Post-procedural complication rate was 2.2%. One-year AF-free survival rate was 78.6% and the PeAF patients showed poorer survival rate than the ones with other types (PeAF 72.4%, PAF 84.2%, redo AF 80.0%). Additional NPVA did not influence the recurrence of AF in the PAF patients (PVI 17.0% vs. NPVA 14.6%, P value 0.302). However, it showed lower AF recurrence rate in the PeAF patients (PVI 34.9% vs. NPVA 24.4%, P value 0.001). Valvular heart disease, left atrial diameter, PeAF, PVI alone, need of NPVA for terminating AF, and failed ablation were independent predictors of AF recurrence. Conclusions Additional NPVA was associated better rhythm outcome in the patients with PeAF, not in the ones with PAF. The independent risk factors for AF recurrence in Korean population were similar to previous studies. Further research is needed to discover optimal AF ablation strategy.This nationwide registry study was supported by a grant from the Korean Heart Rhythm Society 2017