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IntroductionAtrial fibrillation (AF) is the most common arrhythmia and imposes a high burden on the healthcare system. A nurse-led AF outpatient clinic may alleviate the burden on the cardiology outpatient clinic by triaging patients who need care by a cardiologist or general practitioner (GP). However, care and referral patterns after initial assessment in a nurse-led AF outpatient clinic are unknown. We examined the proportion of AF patients assessed in a nurse-led clinic without outpatient follow-up by a cardiologist.MethodsAll patients with AF referred to our tertiary medical centre underwent cardiac work-up in the nurse-led AF outpatient clinic and were prospectively followed. Data on patient characteristics, rhythm monitoring and echocardiography were collected and described. Odds ratio (OR) for continuing care in the nurse-led AF outpatient clinic was calculated.ResultsFrom 2014 to 2018, 478 consecutive individual patients were referred to the nurse-led AF outpatient clinic. After the initial cardiac work-up, 139 patients (29.1%) remained under nurse-led care and 121 (25.3%) were referred to a cardiologist and 218 (45.6%) to a GP. Patients who remained under nurse-led care were significantly younger, were more symptomatic, more often had paroxysmal AF and had less comorbidities than the other two groups. After multivariable testing, CHA2DS2-VASc score ≥ 2 was associated with discontinued nurse-led care (OR 0.57, 95% confidence interval 0.34–0.95).ConclusionAfter initial cardiac assessment in the nurse-led outpatient clinic, about half of the newly referred AF patients were referred back to their GP. This strategy may reduce the burden of AF patients on secondary or tertiary cardiology outpatient clinics.

ObjectivesTo determine the association between left atrial epicardial conduction time (LAECT), fibrosis and atrial fibrillation (AF) recurrence after thoracoscopic surgical ablation of persistent AF.SettingSingle tertiary care centre in the Netherlands.ParticipantsPatients with persistent AF from the randomised Atrial Fibrillation Ablation and Autonomic Modulation via Thoracoscopic Surgery (AFACT)-trial were included. Patients eligible for thoracoscopic AF ablation were included, full inclusion and exclusion criteria were previously published. All patients underwent thoracoscopic ablation, encompassing pulmonary vein isolation with an additional roof and trigone lesion. In patients with conduction block across the roof and trigone lesion, LAECT was measured. LAECT was defined as the time to local activation at one side of the roofline on pacing from the opposite side. Collagen fibre density was quantified from left atrial appendage histology.Outcome measuresPrimary outcome: AF recurrence during 2 years of follow-up.Results121 patients were included, of whom 35(29%) were women, age was 60.4±7.8 and 51% (62) had at least one AF recurrence during 2 years of follow-up. LAECT was longer in patients with versus without AF recurrence (182±43 ms vs 147±29 ms, pConclusionLAECT is correlated with collagen fibre density and BMI and is independently associated with AF recurrence in patients with persistent AF. In these patients, LAECT appears to reflect substrate characteristics beyond clinical AF type and left atrial volume.Trial registration numberNCT01091389.

BACKGROUND: Monosodium glutamate (MSG), also referred to as Vetsin or E621, is a flavour enhancer frequently used in Asian cuisine and abundantly present in the famous Chinese dish Peking duck. MSG is notorious for triggering the onset of the so-called 'Chinese restaurant syndrome' (CRS), a complex of unpleasant symptoms, which might include flushing, sweating and the onset of atrial fibrillation (AF). This study aims to determine the effects of MSG on the occurrence of AF. METHODS: We conducted a placebo self-controlled single-arm study in the Academic Medical Centre in Amsterdam. We included paroxysmal AF patients who reported a consistent onset of AF upon MSG intake. During three admissions, participants were subsequently administered: placebo, 1.5 g and 3 g MSG. If AF was recorded after the dose of 1.5 g MSG, patients were given another placebo instead of 3 g MSG. The primary outcome was the onset of AF registered by 24-hour Holter monitoring. The secondary outcomes were any other arrhythmia and the onset of CRS defined as two or more symptoms of CRS after MSG intake. RESULTS: Six men participated in the study. Both 1.5 g and 3 g MSG were unrelated to CRS, arrhythmias or AF occurrence. CONCLUSION: Peking duck can be put on the Christmas menu without risking guests to be admitted to the emergency department with new episodes of AF.

Background Atrial fibrosis is a hallmark of atrial fibrillation (AF) and serves as an important arrhythmogenic substrate. It is formed by fibroblasts in response to tissue dyshomeostasis induced by multiple factors such as ageing, hypertension and inflammation. How fibroblasts phenotypically transform into an active form with enhanced profibrotic capacity in AF pathophysiology remains elusive. The primary cilium is an antenna-like small organelle, that function as a sensor to transduce external stimuli to intracellular signaling thereby potentially mediating the fibroblast's profibrotic capacity. Their involvement in AF pathophysiology is not known. Objective To explore the role of fibroblasts' primary cilium in the formation of the atrial fibrosis in AF. Methods Left atrial appendages (LAA) were obtained from persistent AF patients (AF: n=10) and patients without AF undergoing cardiac surgery (control: n=10). Primary cilia were immunostained with anti-acetylated a-tubulin in cryosections of the LAA. The loss of cilia in fibroblasts isolated from fresh LAA (AF: n=3, control: n=3) was induced by RNAi targeting IFT88, an essential factor for cilia formation. Gene expression and protein levels in LAA were quantified by qPCR and western blot, respectively (AF: n=20, control: n=20). Results The ratio of fibroblasts with primary cilium was significantly decreased in LAA of AF cohort (AF: 14.7%±4.6 vs control: 25.9%±3.6, p Primary cilium is disassembled along with degradation of acetylated a-tubulin by HDAC6. Indeed, a negative correlation between the protein levels of acetylated a-tubulin and HDAC6 were observed in the LAA of AF cohort (p Conclusion The formation of primary cilia in fibroblasts is actively suppressed in AF via HEF1/AURKA/HDAC6 cascade, which in turn enhances the profibrotic response of fibroblasts. This study provides an innovative paradigm for fibrosis formation in AF, and implicates that the primary cilium of fibroblasts potentially become a novel therapeutic target to treat the AF substrate.

Background Left atrial (LA) strain has a prognostic value for atrial fibrillation (AF) recurrence after AF ablation. The value of LA strain as a predictor of AF recurrence after thoracoscopic AF surgery in patients in sinus rhythm (SR) or AF during echocardiography is unknown. Purpose To assess the association between LA strain and AF recurrence after thoracoscopic surgery for AF in both patients in SR and AF during baseline echocardiography. Methods Patients participating in the AFACT trial (n=240) with baseline transthoracic echocardiography (TTE) suitable for LA strain analysis were included in this subanalyses. All patients underwent thoracoscopic pulmonary vein isolation (PVI) with left atrial appendage (LAA) exclusion, and were randomized to ganglion plexus (GP) or no GP ablation. LA strain and mechanical dispersion (MD) of the LA reservoir, conduit and contraction phase were determined retrospectively from TTE images of both patients in AF and SR before thoracoscopic AF surgery. AF recurrence was defined as any recorded atrial tachyarrhythmia lasting >30 sec during a one year FU period. Results A total of 204 patients (58.6±7.8 years, 73% male, 57% persistent AF) were included. Of the 204 patients 121 (59%) were in SR and 83 (41%) were in AF during baseline TTE. Patients in SR during TTE had higher LA strain values and lower MD compared to patients in AF. Of all patients, those with AF recurrence had lower LA strain of the reservoir phase (13.0% vs. 16.6%; p=0.003) and contraction phase (7.4% vs. 11.5%; p=0.012). MD of the contraction phase was increased in patients with AF recurrence (65.1msec vs. 19.2 msec; p=0.003). Multivariable cox regression analysis showed an association between LA strain, MD and AF recurrence (figure). Conclusions Left atrial strain and mechanical dispersion prior to thoracoscopic AF surgery are associated with recurrence of AF. LA strain showed to be a valuable tool to add in the decision making for thoracoscopic AF surgery regardless rhythm during baseline echocardiography.