Search

Background: Although several investigations have shown a relationship between increased epicardial adipose tissue (EAT) and atrial fibrillation (AF), the association between EAT and ventricular tachycardia (VT) has not been evaluated., Objective: We investigated the association between EAT and postablation VT recurrence., Methods: Sixty-one consecutive patients (mean age = 62.0 ± 13.9 years) undergoing VT ablation with preprocedural cardiovascular magnetic resonance imaging (CMR) were recruited. EAT thickness was measured using CMR in the right and left atrioventricular grooves (AVGs), right ventricular free wall, and anterior, inferior, and superior interventricular grooves., Results: During a mean follow-up period of 392.9 ± 180.2 days, postablation VT recurrence occurred in 15 (24.6%) patients. EAT thickness was significantly higher in the VT recurrence group than in the nonrecurrent VT group at the right (18.7 ± 5.7 mm vs 14.1 ± 4.4 mm; P = .012) and left (13.3 ± 3.9 mm vs 10.4 ± 4.1 mm; P = .020) AVGs. The best cut-off points for predicting VT recurrence were calculated as 15.5 mm for the right AVG (area under receiver operating characteristic [ROC] curve = 0.74) and 11.5 mm for the left AVG (area under ROC curve = 0.72). Multivariate Cox regression analysis showed that preprocedural right AVG-EAT (hazard ratio: 1.2; 95% confidence interval: [1.06-1.39], P = .004) was the only independent predictor of VT recurrence after adjustment for covariates. Kaplan-Meier analysis showed a difference for postablation VT recurrence between the 2 groups, with right AVG-EAT thickness cut-off value of <15.5 mm vs ≥15.5 mm (log-rank, P = .003)., Conclusions: We suggested a new possible imaging marker for risk stratification of postablation VT recurrence. A higher EAT may be associated with VT recurrence after catheter ablation of VTs., (Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Arrhythmogenic cardiomyopathy (ACM) is an inherited cardiac disease characterized by progressive fibro-fatty myocardial replacement, ventricular arrhythmia, heart failure, and sudden death. Causative mutations can be identified in 60% of patients, and most of them are found in genes encoding mechanical junction proteins of the intercalated disk., Methods: Whole-exome sequencing was performed on the proband of an ACM family. Sanger sequencing was used to screen for mutations the tight junction protein 1 ( TJP1) gene in unrelated patients. Predictions of local structure content and molecular dynamics simulations were performed to investigate the structural impact of the variants., Results: A novel c.2006A>G p.(Y669C) variant in TJP1 gene was identified by whole-exome sequencing in a patient with ACM. TJP1 encodes zonula occludens 1, an intercalated disk protein interacting with proteins of gap junctions and area composita. Additional rare TJP1 variants have been identified in 1 of 40 Italian probands (c.793C>T p.(R265W)) with arrhythmogenic right ventricular cardiomyopathy and in 2 of 43 Dutch/German patients (c. 986C>T, p.(S329L) and c.1079A>T, p.(D360V)) with dilated cardiomyopathy and recurrent ventricular tachycardia. The p.(D360V) variant was identified in a proband also carrying the p.(I156N) pathogenic variant in DSP. All 4 TJP1 variants are predicted to be deleterious and affect highly conserved amino acids, either at the GUK (guanylate kinase)-like domain (p.(Y669C)) or at the disordered region of the protein between the PDZ2 and PDZ3 domains (p.(R265W), p.(S329L), and p.(D360V)). The local unfolding induced by the former promotes structural rearrangements of the GUK domain, whereas the others are predicted to impair the function of the disordered region. Furthermore, rare variants in TJP1 are statistically enriched in patients with ACM relative to controls., Conclusions: We provide here the first evidence linking likely pathogenic TJP1 variants to ACM. Prevalence and pathogenic mechanism of TJP1-mediated ACM remain to be determined.

Background: Arrhythmia recurrences after catheter ablation occur in up to 50% within one year but their prediction remains challenging. Recently, we developed a novel score for the prediction of rhythm outcomes after single AF ablation demonstrating superiority to other scores. The current study was performed to 1) prove the predictive value of the APPLE score in patients undergoing repeat AF ablation and 2) compare it with the CHADS2 and CHA2DS2-VASc scores., Methods: Rhythm outcome between 3-12 months after AF ablation were documented. The APPLE score (one point for Age >65 years, Persistent AF, imPaired eGFR (<60 ml/min/1.73m2), LA diameter ≥43 mm, EF <50%) was calculated in every patient before procedure., Results: 379 consecutive patients from The Leipzig Heart Center AF Ablation Registry (60±10 years, 65% male, 70% paroxysmal AF) undergoing repeat AF catheter ablation were included. Arrhythmia recurrences were observed in 133 patients (35%). While the CHADS2 (AUC 0.577, p = 0.037) and CHA2DS2-VASc scores (AUC 0.590, p = 0.015) demonstrated low predictive value, the APPLE score showed better prediction of arrhythmia recurrences (AUC 0.617, p = 0.002) than other scores (both p<0.001). Compared to patients with an APPLE score of 0, the risk (OR) for arrhythmia recurrences was 2.9, 3.0 and 6.0 (all p<0.01) for APPLE scores 1, 2, or ≥3, respectively., Conclusions: The novel APPLE score is superior to the CHADS2 and CHA2DS2-VASc scores for prediction of rhythm outcomes after repeat AF catheter ablation. It may be helpful to identify patients with low, intermediate or high risk for recurrences after repeat procedure., Competing Interests: The authors have declared that no competing interests exist.

Background: Recurrent atrial fibrillation (AF) occurs in up to 50 % of patients within 1 year after catheter ablation, and a clinical risk score to predict recurrence remains a critical unmet need. The aim of this study was to (1) develop a simple score for the prediction of rhythm outcome following catheter ablation; (2) compare it with the CHADS2 and CHA2DS2-VASc scores, and (3) validate it in an external cohort., Methods: Rhythm outcome between 3 and 12 months after AF catheter ablation were documented. The APPLE score [one point for age >65 years, persistent AF, impaired eGFR (<60 ml/min/1.73 m(2)), LA diameter ≥43 mm, EF < 50 %] was associated with AF recurrence and was validated in an external cohort in 261 patients with comparable ablation and follow-up., Results: In 1145 patients (60 ± 10 years, 65 % male, 62 % paroxysmal AF) the APPLE score showed better prediction of AF recurrences (AUC 0.634, 95 % CI 0.600-0.668, p < 0.001) than CHADS2 (AUC 0.538) and CHA2DS2-VASc (AUC 0.542). Compared to patients with an APPLE score of 0, the odds ratio for AF recurrences was 1.73, 2.79 and 4.70 for APPLE scores 1, 2, or ≥3, respectively (all p < 0.05). In the external validation cohort, the APPLE score showed similar results (AUC 0.624, 95 % CI 0.562-0.687, p < 0.001)., Conclusions: The novel APPLE score is superior to the CHADS2 and CHA2DS2-VASc scores for prediction of rhythm outcome after catheter ablation. It holds promise as a useful tool to identify patients with low, intermediate, and high risk for AF recurrence.

J wave pattern (JWP), characterized by J-point elevation in the anterolateral or inferior leads of the 12-lead electrocardiogram, has been associated with increased risk for idiopathic ventricular fibrillation and mortality. However, its prevalence in syncope of different etiologies is unknown and was evaluated in this study. The study sample comprised 170 consecutive patients with vasovagal syncope or syncope that remained unexplained after complete work-up. JWP in inferior leads and with a horizontal/descending ST-segment is more frequently found in subjects with unexplained syncope than in subjects with vasovagal syncope. This finding may be linked with worse prognosis of unexplained syncope., (Copyright © 2015. Published by Elsevier Inc.)

Background: Females with atrial fibrillation (AF) are at increased risk for ischemic stroke but have been under-represented in AF ablation cohorts. Whether the incidence of TE in women after catheter ablation is higher is unknown. We aimed to analyze the predictive value of thromboembolic scores and other clinical variants for thromboembolism (TE) after AF catheter ablation, separately in women and men., Methods: TE was combined endpoint of early (within first month) and late (during long-term follow-up) stroke, transient ischemic attack, or systemic embolism. Oral anticoagulation was prescribed for 6 months after catheter ablation and discontinued if CHADS2 was <2 and no AF recurrences were documented., Results: The study population (n = 2,069, 66 % male, 60 ± 10 years; 62 % paroxysmal AF) was followed for a median of 18 months (IQR 12-29). Overall 31 TE (1.5 %) occurred with 16 events within 30 days of ablation and 15 TE during the follow-up. Fourteen females (2.0 %) and 17 males (1.2 %) suffered TE (p = 0.128). On multivariate analysis, higher CHADS2 (HR 1.65, 95 % CI 1.10-2.47, p = 0.015), CHA2DS2-VASc (HR 1.42, 95 % CI 1.03-1.96, p = 0.034), R2CHADS2 (HR 1.76, 95 % CI 1.32-2.35, p < 0.001) scores, and eGFR <60 ml/min/1.73 m(2) (HR 3.95, 95 % CI 1.23-12.7, p = 0.021) were significantly associated with TE in men. In females, LV-EF (HR 0.95, 95 % CI 0.91-0.99, p = 0.021) and CHA2DS2-VASc score (HR 1.52, 95 % CI 1.01-2.28, p = 0.044) remained significant predictors for TE., Conclusion: TE rates after AF catheter ablation are low in both genders. In females, LV-EF and CHA2DS2-VASc score and in males all three scores and renal dysfunction were associated with TE.

Background: Common single nucleotide polymorphisms (SNPs) at chromosomes 4q25 (rs2200733, rs10033464 near PITX2), 1q21 (rs13376333 in KCNN3), and 16q22 (rs7193343 in ZFHX3) have consistently been associated with the risk of atrial fibrillation (AF). Single-center studies have shown that 4q25 risk alleles predict recurrence of AF after catheter ablation of AF. Here, we performed a meta-analysis to test the hypothesis that these 4 AF susceptibility SNPs modulate response to AF ablation., Methods and Results: Patients underwent de novo AF ablation between 2008 and 2012 at Vanderbilt University, the Heart Center Leipzig, and Massachusetts General Hospital. The primary outcome was 12-month recurrence, defined as an episode of AF, atrial flutter, or atrial tachycardia lasting >30 seconds after a 3-month blanking period. Multivariable analysis of the individual cohorts using a Cox proportional hazards model was performed. Summary statistics from the 3 centers were analyzed using fixed effects meta-analysis. A total of 991 patients were included (Vanderbilt University, 245; Heart Center Leipzig, 659; and Massachusetts General Hospital, 87). The overall single procedure 12-month recurrence rate was 42%. The overall risk allele frequency for these SNPs ranged from 12% to 35%. Using a dominant genetic model, the 4q25 SNP, rs2200733, predicted a 1.4-fold increased risk of recurrence (adjusted hazard ratio,1.3 [95% confidence intervals, 1.1-1.6]; P=0.011). The remaining SNPs, rs10033464 (4q25), rs13376333 (1q21), and rs7193343 (16q22) were not significantly associated with recurrence., Conclusions: Among the 3 genetic loci most strongly associated with AF, the chromosome 4q25 SNP rs2200733 is significantly associated with recurrence of atrial arrhythmias after catheter ablation for AF., (© 2015 American Heart Association, Inc.)

Background: Renal impairment is associated with poor prognosis in the setting of atrial fibrillation (AF). While AF catheter ablation is an effective treatment modality for AF burden reduction and improvement of symptoms, changes in renal function after catheter ablation and their association with rhythm outcome have not been studied in a large contemporary AF ablation cohort., Objective: To determine the association between CHADS2 and CHA2DS2-VASc scores and arrhythmia recurrences with changes in renal function following AF catheter ablation., Methods: Estimated glomerular filtration rate (eGFR) was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation at baseline and during follow-up in 783 patients undergoing de novo AF catheter ablation. Complete rhythm follow-up was achieved in 626 patients (80%) using serial 7-day Holter ECG., Results: The study population (n=783, 61±10 years, 64% men, 57% paroxysmal AF) was followed up at median 20 (IQR 12-27) months. Baseline eGFR correlated with CHADS2 (β=-0.258, p<0.001) and CHA2DS2-VASc scores (β=-0.434, p<0.001). On multivariable analyses, eGFR changes were associated with AF recurrences (B=-0.136, p=0.014), CHADS2 (B=-0.062, p=0.035) and CHA2DS2-VASc scores (B=-0.057, p=0.003)., Conclusions: In patients after AF catheter ablation, eGFR changes during mid-term follow-up are associated with AF recurrences, CHADS2 and CHA2DS2-VASc scores., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Recurrences of atrial fibrillation (AF) occur in up to 30% within 1 year after catheter ablation. This study evaluated the value of CHADS2, R2CHADS2, and CHA2DS2-VASc scores for the prediction of rhythm outcomes after AF catheter ablation., Methods and Results: Using the Leipzig Heart Center AF Ablation Registry, we documented rhythm outcomes within the first 12 months in 2069 patients (67% men; 60±10 years; 35% persistent AF) undergoing AF catheter ablation. AF recurrences were defined as any atrial arrhythmia occurring within the first week (early recurrences, ERAF) and between 3 and 12 months (late recurrences, LRAF) after ablation. ERAF and LRAF occurred in 36% and 33%, respectively. On multivariable analysis, R2CHADS2 (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.02-1.21; P=0.016) and CHA2DS2-VASc (OR, 1.09; 95% CI, 1.017-1.17; P=0.015) scores as well as persistent AF and left atrial diameter were significant predictors for ERAF. Similarly, the same clinical variables remained significant predictors for LRAF even after adjustment for ERAF, which was the strongest predictor for LRAF (HR, 3.12; 95% CI, 2.62-3.71; P<0.001). However, using receiver operating characteristic curve analyses, both scores demonstrated relatively low predictive value for ERAF (area under the curve [AUC], 0.536 [0.510-0.563]; P=0.007; and AUC, 0.547 [0.521-0.573]; P<0.001 for R2CHADS2 and CHA2DS2-VASc, respectively) and LRAF (AUC, 0.548 [0.518-0.578]; P=0.002; and AUC, 0.550 [0.520-0.580]; P=0.001)., Conclusions: R2CHADS2 and CHA2DS2-VASc were associated with rhythm outcomes after catheter ablation. However, AF type, left atrial diameter, and especially ERAF are also significant predictors for LRAF that should be included into new clinical scores for the prediction of rhythm outcomes after catheter ablation.

Background: Left ventricular diastolic dysfunction (LVDD) is common in the general population, but its prevalence in atrial fibrillation (AF), predictors for LVDD in AF and the association between LVDD and AF-related symptom severity has not been well studied., Methods: In 124 consecutive patients (mean age 61 ± 11years, 60% male) with paroxysmal (n = 70) or persistent AF (n = 54) referred for AF catheter ablation, LVDD was evaluated according to current guidelines using transthoracic echocardiography. AF-related symptom severity was quantified using the European Heart Rhythm Association score., Results: LVDD was present in 46 patients (37%). In uni- and multivariable regression analysis, age (OR 1.068 per year, 95% CI 1.023-1.115, P = 0.003) and persistent AF (OR 2.427 vs. paroxysmal AF, 95% CI 1.112-5.3, P = 0.026) were associated with LVDD. LVDD was found in 11% with mild AF symptoms (n = 27) as opposed to 44% in patients with moderate-severe AF symptoms (n = 97, P = 0.002). Thus, the OR for moderate-severe AF symptoms was 6.368 (1.797-22.568, P = 0.004) in the presence of LVDD., Conclusions: LVDD (1) occurs frequently in AF, (2) is associated with advancing age and AF progression and (3) is correlated with symptom severity in AF., (© 2012 Wiley Periodicals, Inc.)

Background: Steerable sheath technology is designed to facilitate catheter access, stability, and tissue contact in target sites of atrial fibrillation (AF) catheter ablation. We hypothesized that rhythm control after interventional AF treatment is more successful using a steerable as compared with a nonsteerable sheath access., Methods and Results: One hundred thirty patients with paroxysmal or persistent drug-refractory AF undergoing their first ablation procedure were prospectively included in a randomized fashion in 2 centers. Ablation was performed by 10 operators with different levels of clinical experience. Treatment outcome was measured with serial 7-day Holter ECGs and additional symptom-based arrhythmia documentation. Single procedure success (freedom from AF and/or atrial macroreentrant tachycardia) was significantly higher in patients ablated with a steerable sheath (78% versus 55% after 3 months, P=0.005; 76% versus 53% after 6 months, P=0.008). Rate of pulmonary vein isolation, procedure duration, and radiofrequency application time did not differ significantly, whereas fluoroscopy time was lower in the steerable sheath group (33±14 minutes versus 45±17 minutes, P<0.001). Complication rates showed no significant difference (3.2% versus 5%, P=0.608). On multivariable analysis, steerable sheath usage remained the only powerful predictor for rhythm outcome after 6 months of follow-up (hazard ratio, 2.837 [1.197 to 6.723])., Conclusions: AF catheter ablation using a manually controlled, steerable sheath for catheter navigation resulted in a significantly higher clinical success rate, with comparable complication rates and with a reduction in periprocedural fluoroscopy time., Clinical Trial Registration: URL: http://clinicaltrials.gov. Unique identifier: NCT00469638.

Introduction: Catheter ablation is potentially curative treatment for atrial fibrillation (AF). However, complications are more frequent and more severe compared with other ablation procedures. We investigated the complication rate in 1,000 AF ablation procedures in a high-volume center and examined possible risk factors., Methods and Results: One thousand consecutive circumferential pulmonary vein radiofrequency ablations were performed for symptomatic, drug-refractory AF. Major complications were defined as the ones that were life threatening, caused permanent harm, and required intervention or prolonged hospitalization. Thirty-nine (3.9%) major periprocedural complications were observed. There was no death immediately associated with the procedure. However, there were 2 deaths (0.2%) of unclear cause, 14 days and 4 weeks after ablation. The most common complications were tamponade (1.3%), treated mainly by percutaneous drainage, and vascular complications (1.1%). There were also 4 thromboembolic events (0.4%): 3 nonfatal strokes and one transient ischemic attack. Importantly, 2 cases (0.2%) of atrial-esophageal fistula and 2 cases (0.2%) of endocarditis were observed. Factors associated with an increased complication risk were age > or = 75 years (hazard ratio 3.977, P = 0.022) and congestive heart failure (hazard ratio 5.174, P = 0.001)., Conclusion: AF ablation still has a considerable number of major complications that may be life threatening or may lead to severe residues. Atrial-esophageal fistula is still observed despite continuous systematic methods to prevent it. Stroke, tamponade, and vascular complications are the most frequent major complications. However, in most patients treatment can be conservative and results in complete recovery. Advanced age and congestive heart failure seem to be associated with an increased risk of complications.