Healthcare Utilization and Clinical Outcomes after Catheter Ablation of Atrial Flutter

Atrial flutter ablation is associated with a high rate of acute procedural success and symptom improvement. The relationship between ablation and other clinical outcomes has been limited to small studies primarily conducted at academic centers. We sought to determine if catheter ablation of atrial flutter is associated with reductions in healthcare utilization, atrial fibrillation, or stroke in a large, real world population. California Healthcare Cost and Utilization Project databases were used to identify patients undergoing atrial flutter ablation between 2005 and 2009. The adjusted association between atrial flutter ablation and healthcare utilization, atrial fibrillation, or stroke was investigated using Cox proportional hazards models. Among 33,004 patients with a diagnosis of atrial flutter observed for a median of 2.1 years, 2,733 (8.2%) underwent catheter ablation. Atrial flutter ablation significantly lowered the adjusted risk of inpatient hospitalization (HR 0.88, 95% CI 0.84–0.92, p<0.001), emergency department visits (HR 0.60, 95% CI 0.54–0.65, p<0.001), and overall hospital-based healthcare utilization (HR 0.94, 95% CI 0.90–0.98, p = 0.001). Atrial flutter ablation was also associated with a statistically significant 11% reduction in the adjusted hazard of atrial fibrillation (HR 0.89, 95% CI 0.81–0.97, p = 0.01). Risk of acute stroke was not significantly reduced after ablation (HR 1.09, 95% CI 0.81–1.45, p = 0.57). In a large, real world population, atrial flutter ablation was associated with significant reductions in hospital-based healthcare utilization and a reduced risk of atrial fibrillation. These findings support the early use of catheter ablation for the treatment of atrial flutter.     

影响心房颤动射频消融术后复发率的相关因素

近年来,随着方法学的不断改进,导管射频消融治疗心房颤动(房颤AF)有了一定程度的提高,但因其随访观察AF再发率较高,为20%左右,限制了此项技术在临床上的应用.如何降低一次消融后的房颤复发率以及房颤复发的原因是目前亟待解决和探讨的焦点问题之一.本文主要对影响房颤消融术后复发的相关因素进行综述.     

Ablation of Post Transplant Atrial Flutter and Pseudo-fibrillation Using Magnetic Navigation via a Superior Approach

Ablation of cavotricuspid isthmus flutter and atrial tachycardia in a complex substrate has never been reported using remote navigation via superior approach. Venous access was obtained via right internal jugular for ablation and left subclavian for duodecapolar catheter placement into the coronary sinus. In a posttransplant patient presenting with both regular and irregular tachycardia, both cavotricuspid isthmus flutter in the donor and atrial tachycardia in the recipient was mapped using a two catheter approach. Successful ablation of typical atrial flutter and anastomotic block was achieved. This is the first report of successful ablation of cavotricuspid isthmus flutter and posttransplant atrial tachycardia using magnetic navigation via superior approach. Using only two catheters, this approach is logical and feasible in complex substrates with interrupted inferior venous access.     

Anatomic Guidance For Ablation: Atrial Flutter,Fibrillation, and Outflow Tract Ventricular Tachycardia

After initial documentation of excellent efficacy with radiofrequency ablation, this procedure is being performed increasingly in more complex situations and for more difficult arrhythmia. In these circumstances, an accurate knowledge of the anatomic basis for the ablation procedure will help maintain this efficacy and improve safety. In this review, we discuss the relevant anatomy for electrophysiology interventions for typical right atrial flutter, atrial fibrillation, and outflow tract ventricular tachycardia. In the pediatric population, maintaining safety is a greater challenge, and here again, knowing the neighboring and regional anatomy of the arrhythmogenic substrate for these arrhythmias may go a long way in preventing complications.     

Risk of Ischemic Stroke after Intracranial Hemorrhage in Patients with Atrial Fibrillation

Background

We aimed to estimate the risk of ischemic stroke after intracranial hemorrhage in patients with atrial fibrillation.

Materials and Methods

Using discharge data from all nonfederal acute care hospitals and emergency departments in California, Florida, and New York from 2005 to 2012, we identified patients at the time of a first-recorded encounter with a diagnosis of atrial fibrillation. Ischemic stroke and intracranial hemorrhage were identified using validated diagnosis codes. Kaplan-Meier survival statistics and Cox proportional hazard analyses were used to evaluate cumulative rates of ischemic stroke and the relationship between incident intracranial hemorrhage and subsequent stroke.

Results

Among 2,084,735 patients with atrial fibrillation, 50,468 (2.4%) developed intracranial hemorrhage and 89,594 (4.3%) developed ischemic stroke during a mean follow-up period of 3.2 years. The 1-year cumulative rate of stroke was 8.1% (95% CI, 7.5–8.7%) after intracerebral hemorrhage, 3.9% (95% CI, 3.5–4.3%) after subdural hemorrhage, and 2.0% (95% CI, 2.0–2.1%) in those without intracranial hemorrhage. After adjustment for the CHA₂DS₂-VASc score, stroke risk was elevated after both intracerebral hemorrhage (hazard ratio [HR], 2.8; 95% CI, 2.6–2.9) and subdural hemorrhage (HR, 1.6; 95% CI, 1.5–1.7). Cumulative 1-year rates of stroke ranged from 0.9% in those with subdural hemorrhage and a CHA₂DS₂-VASc score of 0, to 33.3% in those with intracerebral hemorrhage and a CHA₂DS₂-VASc score of 9.

Conclusions

In a large, heterogeneous cohort, patients with atrial fibrillation faced a substantially heightened risk of ischemic stroke after intracranial hemorrhage. The risk was most marked in those with intracerebral hemorrhage and high CHA₂DS₂-VASc scores.     

老年ST段抬高型心肌梗死后发生恶性室性心律失常的危险因素分析

目的:探讨老年ST段抬高型心肌梗死患者发生恶性室性心律失常的相关危险因素。方法:对150例老年ST段抬高型心肌梗死患者的临床资料进行回顾性分析,根据有无恶性室性心律失常(MVA)将其分为对照组(非MVA)和观察组(MVA),对两组的临床资料及指标进行比较,并进行Logistic回归分析。结果:性别、年龄、吸烟史、高血压史、糖尿病史、心绞痛史、血糖、糖化血红蛋白(Hb A1c)、血钾、肌酐(Cr)、BUN、甘油三脂(TG)、总胆固醇(TC)、高密度脂蛋白(HDL)、低密度脂蛋白(LDL)及病变类型与老年ST段抬高型心肌梗死患者发生MVA的发生无关,Killip分级、Cr和LDL与MVA的发生有关,且Killip分级和Cr水平是发生MVA的独立危险因素。结论:Killip分级和Cr水平是诱发老年ST段抬高型心肌梗死后MVA的独立危险因素。     

Risk Factors and Outcomes for Postoperative Delirium after Major Surgery in Elderly Patients

Background

Early identification of patients at risk for delirium is important, since adequate well timed interventions could prevent occurrence of delirium and related detrimental outcomes. The aim of this study is to evaluate prognostic factors for delirium, including factors describing frailty, in elderly patients undergoing major surgery.

Methods

We included patients of 65 years and older, who underwent elective surgery from March 2013 to November 2014. Patients had surgery for Abdominal Aortic Aneurysm (AAA) or colorectal cancer. Delirium was scored prospectively using the Delirium Observation Screening Scale. Pre- and peri-operative predictors of delirium were analyzed using regression analysis. Outcomes after delirium included adverse events, length of hospital stay, discharge destination and mortality.

Results

We included 232 patients. 51 (22%) underwent surgery for AAA and 181 (78%) for colorectal cancer. Postoperative delirium occurred in 35 patients (15%).Predictors of postoperative delirium included: delirium in medical history (Odds Ratio 12 [95% Confidence Interval 2.7–50]), advancing age (Odds Ratio 2.0 [95% Confidence Interval 1.1–3.8]) per 10 years, and ASA-score ≥3 (Odds Ratio 2.6 [95% Confidence Interval 1.1–5.9]). Occurrence of delirium was related to an increase in adverse events, length of hospital stay and mortality.

Conclusion

Postoperative delirium is a frequent complication after major surgery in elderly patients and is related to an increase in adverse events, length of hospital stay, and mortality. A delirium in the medical history, advanced age, and ASA-score may assist in defining patients at increased risk for delirium. Further attention to prevention of delirium is essential in elderly patients undergoing major surgery.     

Low Left Atrial Compliance Contributes to the Clinical Recurrence of Atrial Fibrillation after Catheter Ablation in Patients with Structurally and Functionally Normal Heart

Stiff left atrial (LA) syndrome was initially reported in post-cardiac surgery patients and known to be associated with low LA compliance. We investigated the physiological and clinical implications of LA compliance by estimating LA pulse pressure (LApp) among patients with atrial fibrillation (AF) and structurally and functionally normal heart. Among 1038 consecutive patients with LA pressure measurements before AF ablation, we included 334 patients with structurally and functionally normal heart (81.7% male, 54.1±10.6 years, 77.0% paroxysmal AF) after excluding those with hypertension, diabetes, and previous ablation or cardiac surgery. We measured LApp (peak-nadir LA pressure) at the beginning of the ablation procedure and compared the values with clinical parameters and the AF recurrence rate.AF patients with normal heart were younger and more frequently male and had paroxysmal AF, a lower body mass index, and a lower LApp compared to others (all p<0.05).Based on the median value, the low LA compliance group (LApp≥13mmHg) had a smaller LA volume index and lower LA voltage (all p<0.05) compared to the high LA compliance group. During a mean follow-up of 16.7±11.8 months, low LA compliance was independently associated with two fold-higher risk of clinical AF recurrence (HR:2.202; 95%CI:1.077–4.503; p = 0.031).Low LA compliance, as determined by an elevated LApp, was associated with a smaller LA volume index and lower LA voltage and independently associated with higher clinical recurrence after catheter ablation in AF patients with structurally and functionally normal heart.     

Galectin-3 in Patients with Atrial Fibrillation Undergoing Radiofrequency Catheter Ablation

Background

Galectin-3 (Gal-3) is an emerging biomarker in heart failure that is involved in fibrosis and inflammation. However, its potential value as a prognostic marker in atrial fibrillation (AF) is unknown. The aim of this study was to assess the impact of AF catheter ablation on Gal-3 and evaluate its prognostic impact for predicting rhythm outcome after catheter ablation.

Methods

Gal-3 was measured at baseline and after 6 months using specific ELISA. AF recurrences were defined as any atrial arrhythmia lasting longer than 30 sec within 6 months after ablation.

Results

In 105 AF patients (65% males, age 62±9 years, 52% paroxysmal AF) undergoing catheter ablation, Gal-3 was measured at baseline and after 6 months and compared with an AF-free control cohort (n=14, 50 % males, age 58±11 years). Gal-3 was higher in AF patients compared with AF-free controls (7.8±2.9 vs. 5.8±1.8, ng/mL, p=0.013). However, on multivariable analysis, BMI (p=0.007) but not AF (p=0.068) was associated with Gal-3. In the AF cohort, on univariable analysis higher Gal-3 levels were associated with female gender (p=0.028), higher BMI (p=0.005) and both CHADS2 (p=0.008) and CHA2DS2-VASC (p=0.016) scores, however, on multivariable analysis only BMI remained significantly associated with baseline Gal-3 (p=0.016). Gal-3 was similar 6 months after AF catheter ablation and was not associated with sinus rhythm maintenance.

Conclusions

Although galectin-3 levels are higher in AF patients, this is driven by cardiometabolic co-morbidities and not heart rhythm. Gal-3 is not useful for predicting rhythm outcome of catheter ablation.     

Oral Bisphosphonates and Risk of Atrial Fibrillation and Flutter in Women: A Self-Controlled Case-Series Safety Analysis

Background

A recent trial unexpectedly reported that atrial fibrillation, when defined as serious, occurred more often in participants randomized to an annual infusion of the relatively new parenteral bisphosphonate, zoledronic acid, than among those given placebo, but had limited power. Two subsequent population-based case-control studies of patients receiving a more established oral bisphosphonate, alendronic acid, reported conflicting results, possibly due to uncontrolled confounding factors.

Methodology/Principal Findings

We used the United Kingdom General Practice Research Database to assess the risk of atrial fibrillation and flutter in women exposed to the oral bisphosphonates, alendronic acid and risedronate sodium. The self-controlled case-series method was used to minimise the potential for confounding. The age-adjusted incidence rate ratio for atrial fibrillation or flutter in individuals during their exposure to these oral bisphosphonates (n = 2195) was 1.07 (95% CI 0.94–1.21). The age-adjusted incidence rate ratio for alendronic acid (n = 1489) and risedronate sodium (n = 649) exposed individuals were 1.09 (95% CI 0.93–1.26) and 0.99 (95% CI 0.78–1.26) respectively. In post-hoc analyses, an increased risk of incident atrial fibrillation or flutter was detected for patients during their first few months of alendronic acid therapy.

Conclusions/Significance

We found no robust evidence of an overall long-term increased risk of atrial fibrillation or flutter associated with continued exposure to the oral bisphosphonates, alendronic acid and risedronate sodium. A possible signal for an increase in risk during the first few months of therapy with alendronic acid needs to be re-assessed in additional studies.     

Assessment of the Correlation Between Two Defining Criteria for Bidirectional Isthmic Block in the Ablation of Typical Atrial Flutter

Background

A complete, bidirectional conduction block in the cavotricuspid isthmus (CTI) represents the end-point of the typical atrial flutter ablation. We investigated the correlation between two criteria for successful ablation, one based on the atrial bipolar electrogram morphology before and after complete CTI conduction block, compared to the standard criteria of differential pacing and reversal in the right atrial depolarization sequence during coronary sinus (CS) pacing.

Method

We conducted a retrospective study in 111 patients (81 males, average age 62±10 years) who underwent an atrial flutter ablation during September 2007 - July 2009 in the Cardiology - Rehabilitation Hospital, UMF Cluj-Napoca. We assessed the presence of a bidirectional block at the end of the procedure using the standard criteria. We then analyzed the morphology of the bipolar atrial electrograms adjacent to the ablation line, before and after CTI conduction block.

Results

A change from a qRs morphology to a rSr'' morphology when pacing from the coronary sinus and from a rsr'' morphology to a QRS morphology when pacing from the low-lateral right atrium was associated with a CTI conduction block. Sensitivity (Se), specificity(Sp), positive predictive value (PPV), negative predictive value (NPV) were 96%, 89%, 99% and 67% respectively.

Conclusion

Our study suggests that the analysis of the atrial bipolar electrogram next to the ablation line before and after CTI ablation may be used as a reliable criterion to validate CTI conduction block due to its high sensitivity, specificity and positive predictive value.     

Evaluation Of Atrial Fibrillation Burden Before Catheter Ablation Predicts Outcome After Pulmonary Vein Isolation

Background

Paroxysmal atrial fibrillation (PAF) is defined as recurrent AF terminating spontaneously within 7 days. This definition allows the consideration of any AF occurrence lasting < 7 days as paroxysmal, irrespective of the frequency and duration of episodes. The aim of this study was to investigate symptomatic AF burden (AFB) defined as total duration of symptomatic AF episodes within 3 months prior to abalation, for prediction of outcome after pulmonary vein isolation (PVI).

Methods

A total of 320 consecutive patients with symptomatic AF (PAF=244, men=214, age=58 y) were enrolled. AFB in patients with PAF was defined as time spent in AF within 3 months prior to PVI. After the AFB cut-off point was optimized at 500 h, patients with PAF were categorized into 2 groups: Group 1 - patients with AFB< 500 h (n=192), Group 2 - patients with AFB≥ 500 h (n=52). Patients with persistent AF (PersAF, n = 76) comprised control group (Group 3). PVI was performed either with irrigated tip catheter (n=215) or using cryoballoon (n=105). The endpoint of study was first documented recurrence of AF >30 sec.

Results

Symptomatic AFB was found to be appropriate for prediction of outcome after PVI. The freedom from AF within 2 years was observed in 69%, 31%, and 43% patients in Group 1, 2 and 3, respectively (Group 1 vs. Group 2, p < .001; Group 1 vs. Group 3, p< .001; Group 2 vs. Group 3, p = 0.46).

Conclusions

Low AFB < 500 h /3 months was associated with better outcome after PVI. Patients with PAF and high AFB should be treated as patients with PersAF.     

Successful Ablation of Cavotricuspid Isthmus-dependent Atrial Flutter Guided by Contact Force Vector in a Patient After a Tricuspid Valve Replacement

A 46-year-old man after a tricuspid valve replacement due to traumatic severe tricuspid regurgitation developed cavotricuspid isthmus-dependent counterclockwise atrial flutter. During a linear ablation using a contact force-sensing irrigated ablation catheter, the flutter could be terminated by a radiofrequency application within a deep pouch just below the bioprosthetic tricuspid valve.     

Successful Non-fluoroscopic Radiofrequency Ablation of Incessant Atrial Tachycardia in a High Risk Twin Pregnancy

We describe a patient presenting with incessant ectopic atrial tachycardia during a high risk twin pregnancy. Tachycardia was resistant to escalating doses of beta-blockade with digoxin. Because of increasing left ventricular dysfunction early in the third trimester, catheter ablation was performed successfully at 30 weeks gestation. Electro-anatomic mapping permitted the entire procedure to be conducted without the use of ionizing radiation. The pregnancy proceeded to successful delivery near term and after three years the patient remains recurrence free with normal left ventricular function, off all medication.     

Robotic Ablation of Atrial Fibrillation

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between pulmonary vein (PV) and left atrium (LA) is created. This conduction block prevents AF, which is triggered by irregular electric activity originating from the PV. However, transmural atrial lesions are required which can be challenging. Re-conduction and AF recurrence occur in 20 - 40% of the cases. Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new remote catheter system (RCS), is presented. Objective of this article is to show feasibility of robotic AF ablation with a novel system. Materials and Methods: After interatrial trans-septal puncture is performed using a long sheath and needle under fluoroscopic guidance. The needle is removed and a guide wire is placed in the left superior PV. Then an ablation catheter is positioned in the LA, using the sheath and wire as guide to the LA. LA angiography is performed over the sheath. A circular mapping catheter is positioned via the long sheath into the LA and a three-dimensional (3-D) anatomical reconstruction of the LA is performed. The handle of the ablation catheter is positioned in the robotic arm of the Amigo system and the ablation procedure begins. During the ablation procedure, the operator manipulates the ablation catheter via the robotic arm with the use of a remote control. The ablation is performed by creating point-by-point lesions around the left and right PV ostia. Contact force is measured at the catheter tip to provide feedback of catheter-tissue contact. Conduction block is confirmed by recording the PV potentials on the circular mapping catheter and by pacing maneuvers. The operator stays out of the radiationfield during ablation. Conclusion: The novel catheter system allows ablation with high stability on low operator fluoroscopy exposure.     

射频消融术治疗房颤后并发血栓栓塞形成的机制

心房颤动是临床上常见的心律失常之一,可因心房丧失收缩功能及长期心率增快而导致心房内血栓形成,并脱落至身体各处形成栓塞,严重时甚至可导致心力衰竭,增加患者的死亡率。射频消融术是目前可治愈心房颤动的有效的治疗手段,且在老年患者中具有较高的成功率和安全性。但血栓形成和栓塞仍是其主要并发症之一,发生率甚至可高达7%,一旦栓塞事件发生,将严重影响患者术后生存质量。目前研究结果表明,射频消融术治疗心房颤动后发生血栓及栓塞是一种多因素参与的系统性改变。     

beta受体阻断药在心力衰竭合并房颤治疗中的再评价

β肾上腺素受体阻断药被认定为心力衰竭治疗领域的里程碑,在心力衰竭指南中,β肾上腺素受体阻断药为IA类推荐。但针对慢性心力衰竭的经典、大型RCT临床试验中,房颤患者所占比率不高。新近对于心力衰竭合并房颤患者应用β肾上腺素受体阻断剂的死亡率和住院率进行Meta-分析示:β肾上腺素受体拮抗剂未见有更多临床获益(即死亡率和住院率减低水平无统计学意义)。本文就心力衰竭定义、心力衰竭时交感神经系统激活、作用于交感神经系统的β肾上腺素受体阻断药药理作用及分类、β肾上腺素受体阻断药在心力衰竭并发房颤治疗中应用地位、心力衰竭并发房颤患者应用β肾上腺素受体阻断药存在的争议及其原因分析进行简要综述。     

胺碘酮对急诊老年快速心房颤动患者的疗效观察

目的:通过与传统控制心室率的药物去乙酰毛花苷注射液进行对比,探讨胺碘酮注射液对老年快速型心房颤动患者的临床疗效.方法:选择2010年5月～2012年6月我院急诊科收治的老年快速房颤患者60例,按就诊先后顺序随机分为对照组与胺碘酮治疗组,每组30例.胺碘酮治疗组患者先给予胺碘酮注射液150 mg以生理盐水稀释后缓慢静脉注射,继以0.5 mg/min静滴;对照组患者先予去乙酰毛花苷注射液0.2 mg稀释后缓慢静脉推注,若20 min无效则再次给药,两组患者的院内观察周期均为24h,患者在观察过程中行全程心电监护,观察不同时间段(用药后0、0.5、2、12、24 h)患者的心室率,血压的变化;比较两种治疗方法的临床疗效及对患者复律情况的影响.结果:治疗前,两组患者的心室率比较无显著性差异(P＞0.05);第一次用药后0.5h,两组患者的心室率都较治疗前显著下降(P＜0.01),且用乙酰毛花苷注射液治疗的对照组显著低于胺碘酮治疗组(P＜0.05);用药后2和12h,两组患者的心室率比较均无显著性差异(P＞0.05);用药后24h,胺碘酮治疗组患者的心室率较对照组显著降低(P＜0.01).对照组的临床有效率为40.0％,复律率为l6.7％;而胺碘酮治疗组的临床有效率为73.3％,复律率为43.3％,分别显著高于对照组(P＜0.01).与用药前比较,用药后0.5、2、12和24h患者的收缩压略有下降,但差异均无统计学意义(P＞0.05).结论:与去乙酰毛花苷注射液比较,胺碘酮注射液可更有效地降低老年患者24h心室率,复律率和有效率更高,但在应用过程中需注意其不良反应.     

血清尿酸、超敏C 反应蛋白与老年永久性房颤的关系

目的:探讨血清尿酸(UA)、超敏C反应蛋白(hs-CRP)、左心房内径(LAD)与老年永久性房颤的相关性。方法:选取2012年8月至2015年9月于首都医科大学宣武医院综合科住院的老年永久性房颤患者78例作为房颤组,选取同期住院窦性心律且无房颤病史的老年患者72例作为对照组,记录各组一般资料及超声心动图、尿酸、hs-CRP水平等,进行比较及相关性分析。结果:1与对照组相比,房颤组血清UA及hs CRP水平、左心房内径大小明显增高(P0.05),2以房颤是否发生为因变量,多因素logistic回归分析显示血清尿酸(OR=2.016,P=0.004)、左房内径(OR=4.180,P=0.001)和hs-CRP(OR=2.846,P=0.002)是老年永久性房颤发生的独立危险因素。3房颤组患者血清尿酸与hs-CRP水平呈正相关(r=0.28,P0.05),尿酸与左心房内径大小呈轻度正相关(r=0.12,P0.05)。结论:血清尿酸、hs-CRP、左房内径是老年永久性房颤发生的独立危险因素;尿酸参与的炎症反应和结构重构可能参与老年永久性房颤的发生。