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Background:Prior studies have reported an approximate 4% increase in new-onset atrial fibrillation (AF) with each unit increase in the body mass index (BMI), when BMI is investigated as a continuous variable.Objective:To assess the association BMI with hypertension (HTN), diabetes (DM), sleep apnea (OSA) and prevalence of left atrial (LA) scar along with long-term ablation success in AF patients undergoing catheter ablationMethods:Based on the baseline BMI, 4,236 consecutive AF patients undergoing AF ablation were classified into group I: BMI ?25 (n=975), group II: BMI 26-35 (n=2507) and group III: BMI >35 (n=754). Documented clinical diagnosis was accepted as evidence for presence of HTN, OSA or DM. LA scarring (bipolar voltage amplitude <0.5 mV) was determined by 3D voltage mapping. All received isolation of pulmonary veins, LA posterior wall and superior vena cava. Moreover, sustained non-PV triggers were ablated upon detection by isoproterenol challenge. Patients were followed up with quarterly arrhythmia monitoring for recurrence.Results:Baseline characteristics and the correlation of BMI classes with the endpoints is presented in the figure. An increase in the rate of HTN, DM and OSA was observed with increase in the BMI, which was significantly different (p<0.001) across the groups. Additionally, scar prevalence in group III was significantly higher than that in the other two groups (p=0.002). However, the recurrence rate off-antiarrhythmic drugs at 1-year follow-up after single procedure was comparable across the BMI classes.Conclusion:Our findings demonstrated higher BMI to be associated with increase in the rate of HTN, OSA, DM and LA scar, although it did not influence the ablation outcome in patients with atrial fibrillation. Our extensive ablation strategy could be the possible reason for this comparable outcome.Figure:

Introduction:Clopigodrel is used after Watchman implant to prevent device-related thrombosis (DRT) that might occur before endothelialization is complete.Hypothesis:We sought to evaluate the prevalence loss-of-function polymorphisms of CYP2C19 and the incidence of DRT when clopidogrel is replaced with prasugrel or half dose of novel OAC in patients with reduced metabolism.Methods:Watchman patients were genotyped for CYP2C19 polymorphisms with an assay using a polymerase chain reaction with allele-specific primer extension. Patients were classified as having normal, reduced or increased clopidogrel metabolism. Patients with reduced metabolism were considered resistant to clopidogrel and, if no contraindication existed, received prasugrel or half dose of novel OAC during the dual anti-platelet therapy (DAPT) phase following Watchman implant.Results:Overall, 322 patients (mean age: 74?9 yrs, 60% males, CHA2DS2-VASc: 4.6?1.6; HAS-BLED: 3.3?1.3) were genotyped for CYP2C19 polymorphisms (Group I). Of them, 41% were normal metabolizers, 31% increased, 28% reduce and reduced to normal. Among patients with clopidogrel resistance (n=74), 16.2% (n=12) received ASA and prasugrel during the 6mo DAPT phase, 55.4% (n=41) were prescribed with aspirin plus half dose of novel OAC, 9.5% (n=7) were kept on ASA plus OAC due to the presence of a significant peri-device leak, and the remaining 18.9% (n=14) had a history of cerebrovascular accident and received ASA and clopidogrel. Mean age, CHA2DS2-VASc, HAS-BLED, and follow-up duration were not different between Group I and Group II (control group, n=88). During the DAPT phase, DRT was observed in 1 (0.3%) patient of Group I and 3 (3.4%) of Group II (p=0.032). On multivariate analysis, the genetic-based anti-thrombotic strategy was the only predictor of DRT during the DAPT phase (OR:0.033; 95% CI: 0.003 - 0.337; p-value: 0.004).Conclusions:Approximately 25% of our Watchman patients had clopidogrel resistance. In our population, substitution of clopidogrel with prasugrel or half dose of novel OAC in patients with reduced clopidogrel metabolism significantly decreased the incidence of DRT.

Introduction:Left atrial appendage occlusion (LAAO) might be particularly attractive in CKD patients, owing to a high risk of thromboembolic (TE) events and an even higher risk of bleeding.Hypothesis:We sought to evaluate the safety and effectiveness of LAAO in patients with CKD.Methods:A total of 546 patients undergoing LAAO at 2 centres were enrolled in a prospective registry. On the basis of kidney function, as assessed via the CKD-EPI formula, patients were classified in two groups. Group1 had a glomerular filtration rate value ?60mL/min/1.73m2(CKD stages 3a-b, 4, and 5), whereas Group2 had a function >60mL/min/1.73m2(CKD stages 1 and 2).Results:Compared to Group2 (n=379, 61.7% males), patients in Group1 (n=167, 62.8% males) were older (mean age: 77?6 vs 72?6, p<0.0001), and were at higher risk (CHA2DS2-VASc: 4.7?1.7 vs 4.1?1.5; HAS-BLED: 3.6?1.1 vs 3.1?0.9; p<0.0001 for both). Procedural complications were observed in 2.4% of patients in Group1 and 2.7% of those in Group2 (p=0.99); of them, major procedural adverse events occurred in 4 patients of Group1 (2.4%) and in 5 (1.4%) of Group2 (p=0.67). During a mean follow-up of 15.2?9.3 months, 5 stroke/TIA and 11 major bleeding events were observed in Group1. Rate of TE events was not statistically different between groups (p=0.73); overall major bleeding events showed a higher trend in Group1 (6.6% vs 2.9%, p=0.061). Based on the estimated annual TE risk according to the CHA2DS2-VASc score, the % risk reduction after LAAO was 62.4% and 69.3%, respectively. Based on the estimated annual major bleeding risk based on the HAS-BLED score, the % bleeding risk reduction was 41.2% in Group1 and 61.2% in Group2.Conclusions:LAAO is a safe approach in CKD patients. Given the increased risk of bleeding and the contraindications to oral anticoagulation, CKD patients might be good candidates for percutaneous occlusion of the left atrial appendage.

Introduction:Chronic Alcohol drinking has been associated with an increased incidence of atrial fibrillation (AF). A relationship between alcohol consumption patterns and development of various electrophysiological abnormalities of cardiac substrate has been reported.Hypothesis:We aimed at elucidating the effect of alcohol intake on the outcomes of AF catheter ablation.Methods:Between January 2014 and January 2018, 2453 patients underwent their first AF catheter ablation at our institution. Alcohol intake was classified as 1-4 drinks/week (light drinkers), 5-7 drinks/week (moderate drinkers), or >7 drinks/week (heavy drinkers). In order to attenuate the observed imbalance in baseline parameters between groups, we performed a 1:3 propensity score (PS) matching with alcohol consumption as dependent variable and baseline and clinical characteristics as covariates. Moderate/severe drinkers (Group1, n=135) were compared with 405 matched non-drinkers or light drinkers (Group2). Matching was performed without replacement and a calliper of 0.002 of the standard deviation.Long-term success was assessed off-antiarrhythmic drugs.Results:The mean age of the population was 64?9 and 83% of patients were males. The ratio of paroxysmal AF was 45%. Matched populations had similar demographic and comorbidity profiles, including hypertension (56%), diabetes (17%), sleep-related breathing disorders (19%), coronary artery disease (21%), and heart failure (14%). Severe left atrial scar was present in 21% of patients in Group1 and 13% in Group2 (p=0.037). After pulmonary vein (PV) isolation and high-dose isoproterenol infusion, triggers from non-PV sites were documented in 67% and 54% of patients in Group1 and 2, respectively. After 21?6 months of follow-up, arrhythmia-free survival was similar between groups (64% vs. 68%; p=0.24).In comparison to Group2, Group1 patients who underwent PV isolation alone without ablation of extra-PV triggers had significantly worse outcomes (44% vs. 63%; p=0.024).Conclusions:In our population, moderate-severe alcohol consumption was associated with structural atrial remodeling and increased incidence of extra-PV triggers. Elimination of those triggers resulted in improved arrhythmia-free survival.

Introduction:Atrio-esophageal fistula (AEF) is a rare but catastrophic complication of atrial fibrillation (AF) ablation procedures. Chest computed tomography (CT) is considered for the diagnosis of AEF. However, there are several instances when the CT image might be interpreted as normal in the presence of a fistula, especially in the early stages.Hypothesis:Hereby we present a systematic review of published reports describing clinical manifestations, CT scan findings, and outcomes in patients with a diagnosis of AEF.Methods:An extensive literature search was performed on Pubmed and MEDLINE databases and reference lists of selected articles for reports on unremarkable CT findings in the presence of AEF developing from AF ablation. A total of 96 reports were selected.Results:Overall, 158 cases of AEF following AF ablation were included in the analysis (75.7% males, age 27-85). All patients presented with non-specific symptoms such as chest pain (30.1%), dysphagia (27.8%), fever (53.4%), sepsis (12.8%) after an average 19?12 days post-ablation. The mean time from ablation to hospitalization was 25?12 days. Stroke or transient ischemic attack occurred in 43.9% and 6.8% of patients, respectively. Of the 158 cases, 124 underwent chest CT scan, which was initially unremarkable or inconclusive in 30 (24.2%) cases, resulting in delay in the diagnosis and therapeutic intervention. Fourteen of them underwent repeat chest CT scan and the diagnosis was confirmed in all. Overall, this imaging modality was diagnostic in 108 (87.1%) patients after single or repeat scan. Mortality rates of AEF were 97% with medical management alone, 63% with stent placement, and 34% with surgical intervention. Among survivors, 24 (36.4%) had residual neurological abnormalities at follow-up.Conclusions:Chest CT might have limited sensitivity in detecting AEF. Whether this reflects inadequate protocol or interpretation error is unclear. Therefore, under clinical suspicion, therapeutic decisions should be promptly taken to prevent mortality.

Introduction:Incomplete left atrial appendage (LAA) closure is common after interventional therapies targeting the LAA, potentially hindering an effective thromboembolic (TE) prevention. Detachable coils have found a wide range of applications for transcatheter vascular occlusion/embolization procedures.Hypothesis:We report the feasibility and efficacy of transcatheter leak closure with detachable coils in patients with incomplete LAA closure.Methods:Thirty consecutive high TE-risk patients with a clinically-relevant residual leak (mean age: 72?9 years; 73.3% males; CHA2DS2-VASc: 4.4?1.4; HAS-BLED: 3.6?0.8) underwent percutaneous closure of the LAA patency via embolization coils. Trans-esophageal echocardiography (TEE) was performed at 60?15 days post-procedure.Results:LAA closure had been previously attempted with a Watchman device in 25 patients, an Amulet in 2, and a LARIAT in 3. Baseline TEE documented moderate and severe leaks in 20 (66.7%) and 10 (33.3%) patients, respectively. Procedure and fluoroscopy times were 76?41min and 21?14min, respectively; the mean volume of iodinated contrast medium used was 80?47mL. Coil deployment was successful in all cases. The overall complication rate was 6.1%. After a median follow-up of 54 days (range: 43-265) and an average of 1.1 procedures/patient, TEE revealed complete LAA sealing or a negligible residual leak in 28 cases (93.3%; 25 with no residual leak, 3 with a minimal-mild residual one), and a moderate residual leak in 2 patients (6.7%).Conclusions:Transcatheter LAA leak occlusion via endovascular coils appears to be a safe, effective, and promising approach in high TE-risk patients with incomplete LAA closure.

Introduction:Dressler?s syndrome is a secondary form of pleuro-pericarditis caused by an immune system response to heart damage. The onset of Dressler?s syndrome following catheter ablation (CA) has been previously described in rare case reports.Hypothesis:We sought to report clinical manifestations, management, and outcomes of Dressler?s syndrome after atrial fibrillation (AF) CA.Methods:Data from five AF patients who underwent radiofrequency CA that was complicated by the development of Dressler?s syndrome were extracted from a prospective, single-center database.Results:Five out of 12747 patients (0.04%) developed Dressler?s syndrome post AF ablation, 100% of which were females, with a mean age of 75.8?3.4 years. All patients had persistent AF, and had pulmonary vein (PV) antrum, plus posterior wall isolation, plus non-PV trigger ablation. The mean procedure, fluoroscopy, and radiofrequency times were 183.20?48.0, 50.3?24.0, and 78.03?27.9 min, respectively. All procedures were uncomplicated, and patients were discharged after overnight observation. Hospital re-admission was required in all after an average of 13.2?5.2 days, due to worsening dyspnea, pleuritic pain, and low-grade fever. At re-admission, all 5 patients had moderate-severe leucocytosis with neutrophilia, as well as bilateral rales and pericardial friction rub. Transthoracic echocardiography showed a mean pericardial circumferential effusion of 8?2 mm, and chest X-ray was suggestive of bilateral mild pleural effusion in all. Corticosteroids were prescribed in 3 and NSAIDs plus colchicine in 2 patients. Pericardial drain placement was required in 3 patients after a median of 3 days, due to increasing pericardial effusion with hemodynamic impairment. The drainage tube was removed after a median of 2 days. All patients had complete resolution of symptoms and remained free from pericardial/pleural effusion within 1-month post-admission. Four of 5 patients had repeat CA without recurrent Dressler?s syndrome.Conclusions:Dressler?s syndrome occurred in older female patients, who underwent extensive CA for AF. If promptly treated, its clinical course appears favorable with complete resolution of symptoms and pleuro-pericardial involvement.