Search

Background Arrhythmogenic cardiomyopathy (ACM) is an inherited heart muscle disease characterized by fibro-fatty replacement of predominantly right, left or biventricular myocardium. The clinical course of ACM is characterized by high risk of abrupt arrhythmic ventricular events, potentially leading to sudden cardiac death (SCD), and by progressive impairment of biventricular systolic function, which may lead to heart failure (HF)-related death, with an estimated overall yearly mortality ranging from 0.08% to 3.6% among studies. Aim This study sought to assess the long-term follow-up of a cohort of ACM patients from the Piedmont region of Italy, specifically evaluating the cumulative incidence of SCD, HF-related death and heart transplantat. Methods Patients who received a definite ACM diagnosis according to the latest available International Task Force Criteria (ITFC) at three different institutions in Piedmont (“Cardinal Massaia” Hospital of Asti, “Azienda Ospedaliera Ordine Mauriziano” of Turin and “Città della Salute e della Scienza” Hospital of Turin) between 1982 and March 2022 were prospectively enrolled. Clinical, electrocardiographic and imaging data were collected at baseline and during follow-up. The occurrence of two coprimary composite endpoints was evaluated, namely the arrhythmic composite endpoint of SCD or aborted SCD and the HF-related composite endpoint, including heart transplant for end-stage HF or cardiac death due to pump failure. Independent predictors of the coprimary composite endpoints were also assessed by means of multivariable analysis. Results The overall population included 97 patients; mean age at diagnosis was 38.2 ± 14.3 years; 66 (68%) patients were male. Median follow-up was 12.9 years (interquartile range 0-38 years). The composite arrhythmic outcome occurred in 10 (10.3%) patients and the composite HF outcome occurred in 13 (13.5%) patients. Overall, 19 (19.6%) patients died: seven (37%) patients died from SCD, four (21%) patients died of end-stage HF and eight (42%) patients died from non-cardiac causes. The cumulative incidence of cardiac death was 1.65% per year. Aborted SCD occurred in 3 (3%) patients, sustained ventricular tachycardias in 51 (52%), HF in 17 (18%) and atrial fibrillation in 21 (22%); forty-seven (48%) underwent an implantable cardioverter defibrillator implantation (ICD) and 8 (8%) patients underwent heart transplant. Mean interval between ACM diagnosis and heart transplant was 130.4 ± 75.3 months. At univariable analysis, the presence at baseline of terminal activation duration (TAD) ≥ 55 ms on surface electrocardiogram (p value 0.037), right atrium dilatation at transthoracic echocardiography (p value 0.021) and cardiac magnetic resonance imaging (p value 0.031) and palpitations as main clinical presentation (p value 0.017) were associated with the occurrence of the arrhythmic endpoint. At multivariable analysis, baseline TAD ≥ 55 msec was the only predictor of the composite arrhythmic endpoint (odds ratio 12.5, 95% confidence interval 1.29 to 121.26, p value 0.029). At univariable analysis, the presence of epsilon waves (p value 0.017), TAD ≥ 55 ms (p value 0.020) and T wave inversion in leads V1-V3 (p value 0.022) on surface electrocardiogram, HF (p value 0.018) or atrial arrhythmias (p value < 0.001) at presentation and New York Heart Association (NYHA) class III to IV at diagnosis (p value 0.002) were significantly associated with the composite HF-related endpoint. At multivariable analysis, the presence of atrial arrhythmias at presentation was the only predictor of the HF-related composite endpoint (odds ratio 10.8, 95% confidence interval 1.29 to 90.32, p value 0.028). Conclusions In this multicenter cohort of 97 ACM patients, the cumulative incidence of cardiac death was 1.65% per year at long-term follow-up. Arrhythmic death accounted for the majority of cardiac fatal events (64%), confirming the peculiar predisposition to SCD of ACM patients. Evolution towards end-stage HF and cardiac death due to pump failure were common.

A 38-year-old woman with curly hair was admitted at the Emergency Department of our Hospital for typical thoracic pain associated with dyspnea and palpitations. Electrocardiogram showed sinus rhythm, 65 bpm, low voltages in the peripheral leads with fragmented QRS complex in the inferior leads and negative T-waves in anterior leads. Initial high-sensitivity cardiac troponin level was 46326 ng/L (n.v. < 16 ng/L). At presentation the patient was treated with Anakinra (anti-interleukin 1) and Metoprolol 200 mg/die because of a past medical history characterized by multiple myocarditis recurrences since 2012. Various therapies had been tested (Aspirin, Ibuprofen, Colchicine, Prednisone, Azathioprine), with a good efficacy of Mycophenolic acid, recently stopped to plan a pregnancy. Transthoracic echocardiography documented normal left ventricle (LV) ejection fraction and no alteration wall motion abnormalities; cardiac-MRI demonstrated LV late gadolinium enhancement with a non-ischemic subepicardial “ring-like” pattern. Endomyocardial biopsy was performed, and the ultrastructural analysis showed mitochondrial hyperplasia with focal swelling and marked alterations of intercalated disks. A high ventricular extrasystolic burden was registered at EKG monitoring. Gene sequencing revealed a pathogenetic variant of the gene coding for Desmoplakin. This is involved in the anchoring of intermediate filaments to desmosomal plaques and its pathogenetic variants are associated with an inflammatory and fibrotic LV predominant cardiomyopathy with an arrhythmogenic evolution (see Padua criteria). In the absence of approved therapies, in agreement with the limited available data and considering patient's history, Micofenolic acid was restarted. At 1-, 3- and 6-month follow-up the patient has remained asymptomatic with progressive declining in troponin levels after discharge.

Few data are available regarding the prevalence of left atrium (LA) thrombi in atrial fibrillation (AF) patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). Methods: We evaluated the prevalence and predictors of LA/LA appendage (LAA) thrombi in non-valvular AF patients treated with NOACs referring to a single centre for a scheduled electrical cardioversion (ECV) or catheter ablation (CA). Transesophageal echocardiography (TEE) was performed within 12 h prior to the index procedure. A total of 352 consecutive patients with non-valvular AF treated with NOACs were included in this analysis (ECV group n = 176 and CA group n = 176) between 2013 and 2018. 85 patients (24.2%) were on dabigatran, 150 (42.7%) on rivaroxaban, 104 (29.6%) on apixaban and 13 (3.7%) on edoxaban. A LA/LAA thrombus was detected by TEE in 27 (7.7%) patients, 18 in the ECV group and nine in the ablation group; 18 (5.1%) patients presented dense LA/LAA spontaneous echo contrast (SEC). Predictors of LA/LAA thrombi were a CHA2DS2-VASc score > 3 (OR 4.54, 95% CI 1.50 − 13.70, p value = .007) and obesity (OR 6.01, 95% CI 1.95 − 18.50, p value = .001). Among real-world patients with non-valvular AF treated with NOACs, we found a high incidence of LA/LAA thrombi compared to previous reports. The main predictors of LA/LAA thrombosis were a CHA2DS2-VASc score > 3 and obesity.

Background and Purpose: Clinical trials on stroke prevention in patients with atrial fibrillation have consistently shown clinical benefit from either warfarin or non–vitamin K antagonist oral anticoagulants (NOACs). NOAC-treated patients have consistently reported to be at lower risk for intracerebral hemorrhage (ICH) than warfarin-treated patients. The aims of this prospective, multicenter, multinational, unmatched, case-control study were (1) to investigate for risk factors that could predict ICH occurring in patients with atrial fibrillation during NOAC treatment and (2) to evaluate the role of CHA 2 DS 2 -VASc and HAS-BLED scores in the same setting. Methods: Cases were consecutive patients with atrial fibrillation who had ICH during NOAC treatment. Controls were consecutive patients with atrial fibrillation who did not have ICH during NOAC treatment. As within the CHA 2 DS 2 -VASc and HAS-BLED scores there are some risk factors in common, several multivariable logistic regression models were performed to identify independent prespecified predictors for ICH events. Results: Four hundred nineteen cases (mean age, 78.8±8.1 years) and 1526 controls (mean age, 76.0±10.3 years) were included in the study. From the different models performed, independent predictors of ICH were increasing age, concomitant use of antiplatelet agents, active malignancy, high risk of fall, hyperlipidemia, low clearance of creatinine, peripheral artery disease, and white matter changes. Low doses of NOACs (given according to label or not) and congestive heart failure were inversely associated with the risk of ICH. HAS-BLED and CHA 2 DS 2 -VASc scores performed poorly in predicting ICH with areas under the curves of 0.496 (95% CI, 0.468–0.525) and 0.530 (95% CI, 0.500–0.560), respectively. Conclusions: Several risk factors were associated to ICH in patients treated with NOACs for stroke prevention but not HAS-BLED and CHA 2 DS 2 -VASc scores.

Background The COVID-19 pandemic dramatically changed lifestyle worldwide, including sport. A comprehensive evaluation of the prevalence of cardiac involvement in COVID-19 is essential to finalize a safe protocol for resuming elite sport. The aim of this study is to evaluate incidence of cardiac involvement and COVID-19 impact on athletic performance. Materials and methods This retrospective observational study analysed the data collected from consecutive competitive athletes who performed medical-sports examinations at the J Medical Center from March 2020 to March 2021. All athletes periodically performed a molecular test using a nasopharyngeal swab to detect COVID-19 infection. Positive athletes performed laboratory (cardiac troponin T—cTnT) and instrumental (echocardiography, stress test, Holter ECG) investigations following recovery to identify any cardiac involvement. Cardiac magnetic resonance imaging (MRI) was performed in case of abnormal findings at first-level evaluation. Results Among 238 athletes (median age 20 years), 77 contracted COVID-19, mainly males (79%) with a median age of 16 years. Fifty-one athletes (66%) presented mild symptoms, and none required hospitalization. Evaluation for resuming sport was performed after a median of 30 days from the first positive test. Abnormal findings were obtained in 13 cases (5 athletes [6%] with elevated cTnT values; 13 athletes [17%] with arrhythmias on Holter ECG and/or during stress test; 2 athletes [3%] anomalies at echocardiography). Cardiac MRI discovered abnormalities in 9 cases, but none of these was clearly related to COVID-19 and none fulfilled acute myocarditis criteria. No negative impact on athletic performance was observed, and none of the athletes developed persistent COVID-related symptoms. Conclusions Our registry confirms the predominantly self-limiting illness in young athlete population. The incidence of clear COVID-19-related structural myocardial injury was very low, but transient exertional ventricular arrhythmias or pericardial effusion was observed without significant impact on athletic performance. Implemented screening for return to activity is likely reasonable only in moderate-to-severe symptomatic athletes.

Background and Purpose— Despite treatment with oral anticoagulants, patients with nonvalvular atrial fibrillation (AF) may experience ischemic cerebrovascular events. The aims of this case-control study in patients with AF were to identify the pathogenesis of and the risk factors for cerebrovascular ischemic events occurring during non–vitamin K antagonist oral anticoagulants (NOACs) therapy for stroke prevention. Methods— Cases were consecutive patients with AF who had acute cerebrovascular ischemic events during NOAC treatment. Controls were consecutive patients with AF who did not have cerebrovascular events during NOACs treatment. Results— Overall, 713 cases (641 ischemic strokes and 72 transient ischemic attacks; median age, 80.0 years; interquartile range, 12; median National Institutes of Health Stroke Scale on admission, 6.0; interquartile range, 10) and 700 controls (median age, 72.0 years; interquartile range, 8) were included in the study. Recurrent stroke was classified as cardioembolic in 455 cases (63.9%) according to the A-S-C-O-D (A, atherosclerosis; S, small vessel disease; C, cardiac pathology; O, other causes; D, dissection) classification. On multivariable analysis, off-label low dose of NOACs (odds ratio [OR], 3.18; 95% CI, 1.95–5.85), atrial enlargement (OR, 6.64; 95% CI, 4.63–9.52), hyperlipidemia (OR, 2.40; 95% CI, 1.83–3.16), and CHA 2 DS 2 -VASc score (OR, 1.72 for each point increase; 95% CI, 1.58–1.88) were associated with ischemic events. Among the CHA 2 DS 2 -VASc components, age was older and presence of diabetes mellitus, congestive heart failure, and history of stroke or transient ischemic attack more common in patients who had acute cerebrovascular ischemic events. Paroxysmal AF was inversely associated with ischemic events (OR, 0.45; 95% CI, 0.33–0.61). Conclusions— In patients with AF treated with NOACs who had a cerebrovascular event, mostly but not exclusively of cardioembolic pathogenesis, off-label low dose, atrial enlargement, hyperlipidemia, and high CHA 2 DS 2 -VASc score were associated with increased risk of cerebrovascular events.

Background: In recent years, direct-acting oral anticoagulants (DOACs) have entered clinical practice for stroke prevention in non-valvular atrial fibrillation or prevention and treatment of venous thromboembolism. However, remaining uncertainty regarding DOAC use in some clinical scenarios commonly encountered in the real world has not been fully explored in clinical trials. Methods: We report on use of a Delphi consensus process on DOAC use in non-valvular atrial fibrillation patients. The consensus process dealt with 9 main topics: (i) DOACs vs vitamin K antagonists in atrial fibrillation (AF) patients; (ii) therapeutic options for patients with stable total time in range treated with vitamin K antagonists; (iii) therapeutic options for patients aged > 85 years; (iv) therapeutic management of hyperfiltering patients; (v) pharmacologic interactions; (vi) therapeutic options in the long-term treatment (prevention) of patients with AF and acute coronary syndrome after the triple therapy; (vii) low doses of DOACs in AF patients; (viii) ischemic stroke in patients inappropriately treated with low doses of DOACs; (ix) management of patients taking DOACs with left atrial appendage thrombosis. Results: A total of 101 physicians (cardiologists, internists, geriatricians, and hematologists) from Italy expressed their level of agreement on each statement by using a 5-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = somewhat agree; 4 = agree; 5 = strongly agree). Votes 1-2 were considered to be disagreement; votes 3-5 were considered to be agreement. Agreement among the respondents of ≥ 66% for each statement was considered consensus. A brief discussion of the results for each topic is also reported. Conclusions: In clinical practice, there is still uncertainty on DOAC use, especially in elderly, fragile, comorbid, and hyperfiltering patients. Résumé: Contexte: Depuis quelques années, les cliniciens prescrivent des anticoagulants oraux directs (AOD) pour prévenir les accidents vasculaires cérébraux (AVC) chez les patients présentant une fibrillation auriculaire (FA) non valvulaire ou pour prévenir et traiter les thromboembolies veineuses. Cependant, les doutes que suscite encore l’emploi des AOD dans certains contextes courants de la pratique clinique n’ont pas encore été bien explorés dans le cadre des études cliniques. Méthodologie: Nous avons utilisé la méthode de Delphes, une démarche visant à dégager un consensus, afin d’évaluer le recours aux AOD chez des patients présentant une FA non valvulaire. L’étude comprenait 9 thèmes principaux : i) utilisation des AOD et des antagonistes de la vitamine K chez les patients présentant une FA; ii) options thérapeutiques pour les patients traités par un antagoniste de la vitamine K dont l’état se maintient depuis un certain temps dans une plage de valeurs normales; iii) options thérapeutiques pour les patients âgés de plus de 85 ans; iv) prise en charge thérapeutique des patients souffrant d’hyperfiltration; v) interactions pharmacologiques; vi) options thérapeutiques pour le traitement prolongé (préventif) des patients présentant une FA et un syndrome coronarien aigu après une trithérapie; vii) utilisation des AOD à faible dose chez les patients présentant une FA; viii) AVC ischémique chez les patients traités de façon inappropriée par un AOD à faible dose; ix) prise en charge des patients prenant un AOD qui présentent une thrombose de l’appendice auriculaire gauche. Résultats: Au total, 101 médecins (cardiologues, internistes, gériatres et hématologues) italiens ont exprimé leur degré d’accord avec chacun des énoncés proposés sur une échelle de Likert à 5 points (1 = tout à fait en désaccord; 2 = en désaccord; 3 = moyennement d’accord; 4 = d’accord; 5 = tout à fait d’accord). Une note de 1 ou 2 a été considérée comme un désaccord et une note de 3, 4 ou 5, comme un accord. On considérait qu’il y avait un consensus si 66 % ou plus des répondants étaient d’accord avec l’énoncé. Nous présentons également brièvement les résultats obtenus pour chacun des thèmes. Conclusions: Dans la pratique clinique, l’emploi des AOD soulève encore des doutes, en particulier chez les patients âgés, fragiles ou présentant des affections concomitantes ou une hyperfiltration.

Introduction Anticoagulantion therapy (OAT) represents the cornerstone to reduce thromboembolic events for atrial fibrillation (AF). Recent studies suggest that AF catheter ablation on top of OAT may be useful to further reduce the thromboembolic risk in AF patients. The aim of the present study is to compare the long-term risk of thromboembolic events and treatment-related complications in patients with AF treated by OAT strategies and catheter ablation. Methods Pubmed, Cochrane and Google Scholar were searched for studies including >500 patients evaluating AF patients treated with OAT (VKA: vitamin K antagonist or DOAC: Direct oral anticoagulants) and/or AF ablation. Pooled incidence of stroke/year was the primary end point, while that of stroke, of all cause bleeding and of major bleeding the secondary ones. All the analyses were stratified according to the CHADS 2 score of included patients. Results Overall, 27 studies were selected, including 50,973 patients in the AF catheter ablation group; 281,595 patients in the VKA group; 54,811 patients in the DOAC group. After a mean follow-up of 2.4 (1.5–3.8) years, the overall incidence of stroke and thromboembolic events was 0.63 per 100 patients/year in AF ablation group, 2.09 per 100 patients/year in VKA group and 1.24 per 100 patients/year in DOAC group ( p 2 score, the incidence of thromboembolic events remained lower in patients included in the AF ablation, followed by DOAC and VKA respectively ( p 2 cluster. Both the incidence of all cause bleedings and major bleedings resulted lower in AF ablation group ( p p Conclusion AF catheter ablation significantly reduces the incidence of long-term thromboembolic events compared to both VKA and DOAC. This reduction is maintained in all CHADS 2 score clusters and is strengthened by the concomitant reduction in hemorrhagic complications provided by AF ablation.

Aims Despite optimal oral anticoagulation with vitamin K antagonist, left atrial (LA) thrombus could be detected in the left appendage (LAA) in >2% of patients with atrial fibrillation (AF) and CHA 2 DS 2 -VASc score≥1 but few data are available for patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). We evaluated the occurrence and predictors of LA thrombi by means of transesophageal echocardiography (TOE) in consecutive patients with non-valvular AF who received for at least 3weeks Apixaban, Dabigatran, or Rivaroxaban. Methods This study included 414 consecutive patients (male 252, 60.6%, mean age 67.3years) referred to our Centers for catheter ablation of AF (n=220, 53.1%) or scheduled electrical cardioversion (n=194, 46.9%). Patients were on Dabigatran (n=160), Rivaroxaban (n=150) or Apixaban (n=104). TOE was performed in all cases within 12h prior to ablation or cardioversion. Results Preprocedural TOE revealed LA thrombus in 15/414 patients (3.6%), all located in the LAA (Apixaban 3/104 2.9%, Dabigatran 5/160 3.1%, and Rivaroxaban 7/150 4.7%, p=0.69). Of these, 14 patients had persistent AF. Patients with LAA thrombus had a mean CHA 2 DS 2 -VASc score of 3 (3–4). Higher CHA 2 DS 2 -VASc score (p=0.02), but not the type of NOAC, significantly predicted the presence of LA thrombus. Conclusion The incidence of LAA thrombus in a cohort of patients anticoagulated with NOACs is low but not negligible, in any case similar among the 3 drugs. Preprocedural TOE should be considered in patients with a CHA 2 DS 2 -VASc score>3.

Aim of this study is to evaluate the impact of antiarrhythmic drugs (AADs) administration for at least one month before ECV on the acute and long term success rate of the procedure.1313 consecutive persistent AF patients were enrolled in 3 different centers (Turin, Asti and Avellino): 692 patients received AADs before and after ECV (group A), 621 patients were treated only after the procedure, at discharge (group B). Primary end point was the restoration and maintenance of sinus rhythm acutely and at a long-term follow up.Acute ECV success was higher in group A compared with group B (99% vs. 88%, p=0.0001) and a fewer number of shock attempts were administered (1.15±0.42 vs. 1.27±0.53 p0.0001). Moreover group A maintained SR more often than group B at one month (99% vs. 89%, log-rank p0.0001), at one year (55% vs. 48% log-rank p=0.01) and at the end of follow up (mean 2.7±2.1years, 45% vs. 29%, log-rank p0.0001). At multivariate analysis AADs premedication was the strongest independent predictor of acute and long-term ECV success (respectively p0.0001 OR 10.71 CI 5.10-22.50 and p=0.004, OR 1.50 CI 1.14-1.97). At sensitivity analysis no differences were found between ADDs in terms of acute success improvement (p=0.605), number of shock attempts (p=0.853) and long term SR maintenance (log-rank p=0.480).AADs administration for at least 4weeks before the ECV in persistent AF increases significantly the acute success rate and this result was maintained over a long-term follow-up.

Aims Net clinical benefit of long-term oral anticoagulation therapy (OAT) continuation after successful atrial fibrillation (AF) ablation is still controversial. To evaluate long-term thromboembolic (TE) and haemorrhagic events incidence according to OAT strategy used after AF transcatheter ablation. Methods and results Three months after AF ablation, OAT was discontinued in patients with CHADS2 ≤ 1 if no recurrences were documented, while OAT was maintained in patients with CHADS2 ≥ 2 regardless of AF recurrences. CHA2DS2VASc and HAS-BLED scores have been retrospectively evaluated. Seven hundred and sixty-six patients were followed for a median of 60.5 months. Six (6/267 = 2.2%) and five (5/499 = 1%) TE events occurred in the ON and the OFF-OAT patients, respectively ( P = 0.145), all in concomitance with the AF recurrence. CHADS2 and CHA2DS2VASc ≥ 2 were associated with high TE incidence ( P = 0.047 and P = 0.020). Among patients with a CHADS2 score of 0 or 1, a CHA2DS2VASc score ≥ 2 was predictive of TE events ( P = 0.014). Overall, the incidence of the TE events in patients with CHA2DS2VASc ≥ 2 was 0.6 per 100 patient-years whereas seven haemorrhagic events occurred, all of them in the ON-OAT patients (7/267 = 2.6%). Conclusion Patients with AF undergoing transcatheter ablation have a lower incidence of TE events as compared with the general AF population, regardless of OAT maintenance. The unpredictable risk of AF recurrence, mandate the routine use of the CHADS2, CHA2DS2VASc, and HAS-BLED scores to guide clinical decision regarding OAT management in this peculiar setting of patients. The potential protective role of rhythm control strategy in the TE events needs to be confirmed by future large randomized trials.

Ablation versus Drugs in Elderly Persistent AF Background We prospectively compared the efficacy, safety, and quality of life (QoL) impact of catheter ablation versus antiarrhythmic drugs (AAD) in elderly patients with persistent atrial fibrillation (AF). Methods and Results Four hundred and twelve consecutive patients, aged ≥ 70 years, underwent ablation (Group A, 153 patients) or AAD (Group B, 259 patients). Study endpoints: treatment failure (any AF/AT lasting >30 seconds) and treatment-related adverse events (acute when ≤1 month of procedure and long term when >1 month). At a follow-up of 60 ± 17 months, 43% and 46% patients in Group B versus 58% and 76% in Group A were in sinus rhythm (SR), respectively, after one (P = 0.003) and 2 procedures (P

Atrial fibrillation increases thromboembolic risk. Oral anticoagulation with antivitamin K (AVK) reduces thromboembolic event rate, but increases hemorrhagic risk.The aim of the present study was to describe long-term cerebral thromboembolic/hemorrhagic event rates in atrial fibrillation patients managed by rhythm control, pursued by atrial fibrillation transcatheter ablation (AFTCA), and rate control strategy.One thousand and five hundred consecutive patients referring to three medical care centers for atrial fibrillation were retrospectively divided into three groups: AFTCA maintaining AVK (group A); AFTCA discontinuing AVK (group B); and rate control strategy and AVK (group C). Thromboembolic and hemorrhagic events were recorded in 60 ± 28 months of follow-up. Thromboembolic events did not differ between the groups (5/500, 1% group A; 7/500, 1.4% group B; 11/500, 2.2% group C; P = 0.45), and hemorrhagic events were greater in group A (9/500, 1.8%) and C (12/500, 2.4%) than in group B (no events; P = 0.003). Among patients with CHA2DS2 VASc score 2 or less, thromboembolic events did not differ in the group discontinuing AVK (group B, 4/388, 1%) or not (group A, 1/319, 0.3%; P = 0.38), whereas hemorrhagic events were more common in patients on AVK (5/319, 1.5% group A and 3/175, 1.7% group C; P = 0.02) compared with those discontinuing AVK (0/388, group B). Following AFTCA (groups A and B), 299/1000 experienced atrial fibrillation relapses; all thromboembolic events (12/299, 4%) occurred within these patients (P 0.001).Considering this multicenter design study, AVK continuation following AFTCA, especially within patients with low-to-intermediate thromboembolic risk, confers a hemorrhagic risk greater to the thromboembolic protective effect. All thromboembolic events following AFTCA occur within patients experiencing atrial fibrillation relapses; therefore, in patients with high thromboembolic risk routine rhythm monitoring is essential after AVK discontinuation.

Background: Current definition of persistent atrial fibrillation (PAF) enrolls a heterogeneous population with different atrial fibrillation (AF) exposure and degree of atrial substrate. Study aims were to evaluate acute and long-term results of electrical cardioversion (ECV) and to identify temporal cutoff of previous AF exposure to reclassify PAF in subgroups with different chance of sinus rhythm (SR) maintenance. Methods: Five hundred twenty-one patients (66% men; age 69 ± 10 years) with PAF undergoing ECV, were divided in four groups according to AF duration at the time of ECV: group A with AF ≤2 months (141 patients); group B with AF >2 and ≤4 months (176 patients); group C with AF >4 and ≤6 months (89 patients); and group D with AF >6 months and 6 months helps in selecting patients that can take greater advantage of the procedure. (PACE 2012; 35:1126–1134)

Background Symptomatic cerebral thromboembolism occurs in 0.4% of transcatheter atrial fibrillation ablation procedures. Silent cerebral events, instead, have recently been reported in up to 14%, especially clustered within patients undergoing cardioversion at the end of the procedure. The present study reports the incidence of silent cerebral thromboembolism, assessed by cerebral MRI, delaying electrical cardioversion, in case of lack of sinus rhythm restoration at the end of the procedure, after 4 weeks of effective anticoagulation. Methods and results Ninety-five consecutive patients with antiarrhythmic drug refractory atrial fibrillation were referred for transcatheter ablation and enrolled in the study. All patients underwent pre-ablation and post-ablation cerebral MRI. Overall, post-ablation cerebral MRI registered new thromboembolism in six (6%) patients. Fifty-five (58%) patients remained in sinus rhythm throughout the procedure and 40 (42%) reported persistent atrial fibrillation, yielding a silent thromboembolism incidence of 5 and 8%, respectively. In particular, silent thromboembolism was registered in one (4%) of the 25 patients achieving sinus rhythm by catheters, in two (18%) of the 11 patients spontaneously restoring sinus rhythm shortly following the procedure and in none of the four patients cardioverted following 4-week anticoagulation. In a matched reference population, a significantly higher percentage of patients (15, 16% vs. 6, 6%; P = 0.03) suffered from a new post-ablation thromboembolism; particularly within patients terminating the procedure in atrial fibrillation. Delaying cardioversion reduced silent cerebral thromboembolism from 38 to 13%. Conclusion Delaying electrical cardioversion after a 4-week anticoagulation period reduced the risk of silent cerebral thromboembolism and is a viable and safer option in patients terminating a transcatheter ablation procedure in atrial fibrillation.

The natural history of atrial fibrillation (AF) is characterized by gradual increase in duration and frequency of relapses until a definitive shift to permanent AF. Heart disease and comorbidities modulate AF progression. However, to date the influence of catheter ablation on AF evolution has rarely been investigated.The purpose of this study was to identify long-term predictors of AF progression in a large cohort of patients undergoing AF transcatheter ablation (AFTCA).A total of 889 patients (mean age 57 ± 11 years; 53.3% paroxysmal AF, 40.5% persistent AF, 6.2% long-standing AF) underwent AFTCA. All patients underwent pulmonary vein isolation, with linear lesions and complex fractionated atrial electrogram ablation reserved for patients with persistent/long-standing AF and/or confirmed structural heart disease.After median follow-up of 64 months (range 41-84 years), AF progression despite AFTCA occurred in 57 cases (6.4%). However, AF progression was much more pronounced in patients with persistent (10%) or long-standing persistent AF (14.6%) than in those with paroxysmal AF (2.7%, P.001). Furthermore, AF progression was more frequently reported in patients who presented with underlying comorbidities/cardiomyopathies (9.1%) than in those who presented with lone AF (29.9%, P.001). At multivariate analysis, comorbidities/cardiomyopathies and baseline persistent/long-standing AF proved to be independent predictors of progression (odds ratio 11.3, 95% confidence interval 2.6-48.0, P.001, and odds ratio 1.6, 95% confidence interval 1.2-2.1, P.001, respectively).The presence of comorbidities/cardiomyopathies and persistent/long-standing AF seem to predict AF progression in patients undergoing AFTCA. Performing AFTCA in the paroxysmal phase of the arrhythmia may reduce progression of AF to its permanent form.

Although many efforts have been directed to improve atrial fibrillation transcatheter ablation safety, thromboembolism to the brain remains one of the major complications. In fact several studies have confirmed occurrence of silent cerebral embolic lesions by post-procedure magnetic resonance imaging. The present review will focus on the possible mechanisms leading to silent cerebral embolism in an attempt to provide recommendations holding the potential to reduce the incidence of this clinically relevant complication.

We prospectively compared the efficacy, safety, and quality of life (QoL) impact of catheter ablation versus antiarrhythmic drugs (AAD) in elderly patients with persistent atrial fibrillation (AF).Four hundred and twelve consecutive patients, aged ≥ 70 years, underwent ablation (Group A, 153 patients) or AAD (Group B, 259 patients). Study endpoints: treatment failure (any AF/AT lasting30 seconds) and treatment-related adverse events (acute when ≤1 month of procedure and long term when1 month). At a follow-up of 60 ± 17 months, 43% and 46% patients in Group B versus 58% and 76% in Group A were in sinus rhythm (SR), respectively, after one (P = 0.003) and 2 procedures (P0.001). Fifteen acute adverse events occurred (6.7% in Group A vs 1% in Group B, P0.001), mainly periprocedural cerebral thromboembolism (3.3% in Group A vs 0.7% in Group B, P = 0.058). Previous TIA/stroke resulted the only independent predictor of periprocedural cerebrovascular accidents (OR 1.2, 95%IC 1.1-1.3). At follow-up, 74 long-term adverse events occurred (7.7% in Group A vs 23.9% in Group B, P0.001) with Group B patients more often experiencing AAD-related adverse events (12.7% vs 2.6%, P0.001). Group A and absence of AF/AT recurrences significantly improved QoL scores (P0.001).In elderly persistent AF patients, catheter ablation is more effective in maintaining SR and in improving QoL than AAD but is affected by a higher risk of embolic complications, particularly in patients with previous TIA/stroke. Over time, Group A patients more likely discontinued AAD with a reduction of long-term adverse events.