Atrial pacing for rhythm control of atrial fibrillation

After atrial fibrillation (AF) develops, the first step is to search for and treat underlying (heart) s. Thereafter, AF should be treated. This includes prevention of cardiovascular morbidity and mortality, especially vascular events, and reduction of symptoms.1 The latter may be obtained by two treatment strategies: rhythm-control and/or rate-control treatment. Recent randomised trials have shown that rate control is not inferior to rhythm control with regard to cardiovascular morbidity and mortality.2 In these studies, predominantly elderly patients with underlying heart s (especially hypertension) were included. Patients with (severely) symptomatic AF and advanced heart failure were excluded. Since then, rate-control treatment has been adopted more frequently, even as first-choice therapy, especially in the elderly.     

Characterizing left atrial appendage functions in sinus rhythm and atrial fibrillation using computational models

Clinical studies show that the left atrial appendage, a blind-ended structure that is attached to the left atrium, may be the cause of 90% of atrial thrombi in atrial fibrillation (abnormal heart rhythm), and it is much reduced in sinus (normal) rhythm. In this paper, the effects of blood flows in left atrium and left atrial appendage are studied to help characterize the atrial appendage functions in sinus rhythm and atrial fibrillation using mathematical models. Our results show that the left atrial appendage is not functional in sinus rhythm because the atrial transmitral velocities remained almost identical for atria with and without appendage, which agrees with the current clinical observations. However, in atrial fibrillation, a proper atrial contraction is absent, which causes the second emptying velocity (A-wave) to be missing in both transmitral velocity and appendage filling/emptying velocity. Without the proper emptying of the blood, vortices generated in the chamber remain high strengths and with longer durations. They induce ineffective emptying of the blood in the atrium and appendage, which then lead to blood stagnation and subsequent thrombus formation.     

Clinical determinants of early spontaneous conversion to sinus rhythm in patients with atrial fibrillation

Netherlands Heart Journal - The current standard of care for acute atrial fibrillation (AF) focuses primarily on immediate restoration of sinus rhythm by cardioversion, although AF often terminates...     

Response of high-sensitive C-reactive protein to catheter ablation of atrial fibrillation and its relation with rhythm outcome

Aims

This study investigated the possible association between hs-CRP as well as hs-CRP changes and rhythm outcome after AF catheter ablation.

Methods

We studied 68 consecutive patients with AF undergoing catheter ablation. hs-CRP levels were measured using commercially available assays before and 6 months after catheter ablation. Serial 7-day Holter ECGs were used to detect AF recurrences.

Results

Early AF recurrence (ERAF, within one week) was observed in 38%, while late AF recurrence (LRAF, between 3 and 6 months) occurred in 18% of the patients. None of the baseline clinical or echocardiographic variables was predictive of ERAF or LRAF. Baseline hs-CRP measured 2.07±1.1 µg/ml and was not associated with ERAF and LRAF. At 6 months, hs-CRP levels were comparable with baseline values (2.14±1.19 µg/ml, p = 0.409) and were also not related with LRAF. However, patients with LRAF showed an hs-CRP increase from 2.03±0.61 to 2.62±1.52 µg/ml (p = 0.028). Patients with an hs-CRP change in the upper tertile (>0.2 µg/ml) had LRAF in 32% as opposed to 11% (p = 0.042) in patients in the lower (<−0.3 µg/ml) or intermediate (−0.3–0.2 µg/ml) tertile.

Conclusions

Changes in hs-CRP but not baseline hs-CRP are associated with rhythm outcome after AF catheter ablation. This finding points to a link between an inflammatory response and AF recurrence in this setting.     

The effect of ranolazine on maintaining sinus rhythm in patients with resistant atrial fibrillation

Background

Atrial fibrillation (AF) may arise out of anomalous impulse activity at atrial venous junctions. Triggered activity may be a source of abnormal impulse activity. Ranolazine is an anti-anginal agent, which inhibits normal and abnormal late Na+ channel current in the ventricle and peak Na+ channel current in the atrium. This produces an energy sparing effect and stabilizes cardiac membranes. Ranolazine is a potent inhibitor of triggered activity. The purpose of this report is to describe our initial experience with ranolazine used in patients with resistant AF.

Methods

Seven patients (4 males, 3 females, 67 ± 9 years) who developed recurrent AF within hours to a few days of restoring sinus rhythm despite AF ablation and /or failing one or more anti-arrhythmic agents were started on ranolazine (500-1000 mg/twice/day) after stopping all other anti-arrhythmic therapy. All but one patient had some form of associated structural heart disease.

Results

Two patients received no apparent benefit from ranolazine developing recurrent AF within 2 days. All other patients derived significant benefit. Four patients have experienced no recurrent AF. The other patient relapsed at 3 months and again at 6 months. The mean time in sinus rhythm to date, or to the first relapse, for the five responders was 27 ± 11 weeks. No clinically evident pro-arrhythmic episodes occurred.

Conclusion

Ranolazine was helpful in maintaining sinus rhythm in the majority of patients in which more established measures had failed. A controlled prospective trial is warranted to further investigate the efficacy of ranolazine in AF.     

Circadian rhythm of atrioventricular conduction predicts long-term survival in patients with chronic atrial fibrillation

The R-R interval of the electrocardiogram during atrial fibrillation (AF) appears absolutely irregular. However, the Poincaré plot of the R-R interval reveals a sector shape of distribution that is unique to AF. Furthermore, the height of lower envelope (LE1.0) of the distribution and the degree of scatter above the envelope (scattering index) may reflect the refractoriness and concealment of atrioventricular (AV) conduction, respectively. We previously observed that both the LE1.0 and scattering index show clear circadian rhythms in patients with chronic AF and that the rhythms are blunted in those with congestive heart failure and chronic AF. In the present study, we examined if the blunted circadian rhythm of the AV conduction has prognostic value in patients with chronic AF. We studied a retrospective cohort of 120 patients who underwent 24h Holter monitoring at baseline. During an observation period of 33 +/- 16 mon, there were 25 deaths (21%) including 13 cardiac and 8 stroke deaths. All patients showed significant circadian rhythms in both LE1.0 and scattering index with acrophases occurring at night; however, patients dying subsequently from cardiac causes, but not those from fatal stroke were blunted in the circadian rhythms (the amplitudes were < 55% of those in surviving patients). Furthermore, the reduced circadian amplitude of scattering index was an increased risk for cardiac death even after adjustment of coexisting cardiovascular risks [adjusted relative risk (95% confidence interval) per 1-SD decrement, 4.24 (1.54-11.6)]. When patients were divided by the circadian amplitude of the scattering index of 36.5 msec (mean minus 1-SD), the 5yr cardiac mortality below and above the cutoff was 57 and 6%, respectively (log-rank test, p < 0.001). We conclude that the blunted circadian rhythm of AV conduction is an independent risk for cardiac death in patients with chronic AF.     

Circadian rhythm of atrioventricular conduction predicts long-term survival in patients with chronic atrial fibrillation

The R–R interval of the electrocardiogram during atrial fibrillation (AF) appears absolutely irregular. However, the Poincaré plot of the R–R interval reveals a sector shape of distribution that is unique to AF. Furthermore, the height of lower envelope (LE_1.0) of the distribution and the degree of scatter above the envelope (scattering index) may reflect the refractoriness and concealment of atrioventricular (AV) conduction, respectively. We previously observed that both the LE_1.0 and scattering index show clear circadian rhythms in patients with chronic AF and that the rhythms are blunted in those with congestive heart failure and chronic AF. In the present study, we examined if the blunted circadian rhythm of the AV conduction has prognostic value in patients with chronic AF. We studied a retrospective cohort of 120 patients who underwent 24h Holter monitoring at baseline. During an observation period of 33±16 mon, there were 25 deaths (21%) including 13 cardiac and 8 stroke deaths. All patients showed significant circadian rhythms in both LE_1.0 and scattering index with acrophases occurring at night; however, patients dying subsequently from cardiac causes, but not those from fatal stroke were blunted in the circadian rhythms (the amplitudes were <55% of those in surviving patients). Furthermore, the reduced circadian amplitude of scattering index was an increased risk for cardiac death even after adjustment of coexisting cardiovascular risks [adjusted relative risk (95% confidence interval) per 1-SD decrement, 4.24 (1.54–11.6)]. When patients were divided by the circadian amplitude of the scattering index of 36.5 msec (mean minus 1-SD), the 5yr cardiac mortality below and above the cutoff was 57 and 6%, respectively (log-rank test, p<0.001). We conclude that the blunted circadian rhythm of AV conduction is an independent risk for cardiac death in patients with chronic AF.