Stavrakis, Stavros

Abstract Atrial fibrillation (AF) is increasingly diagnosed early, close to its first occurrence due to: (i) increased public awareness with self-screening; (ii) health care initiatives including population screening and opportunistic case finding; and (iii) increased use and surveillance of implantable cardiac devices. At its onset, AF is often low burden, and cardiovascular co-morbidities may be absent or at an early stage. Thus, the management of recent-onset AF has become an issue of growing importance. Professional guidelines have traditionally focused on anticoagulant thromboprophylaxis, generally recommending a cautious approach to rhythm control, and priority has been given to rate control to alleviate symptoms. In recent guidelines, the importance of managing lifestyle and co-morbidities has increased. The AF-SCREEN collaboration proposes that a vigorous approach to active management of recent-onset AF may be warranted. This includes addressing co-morbidities and promoting healthy lifestyles to prevent the emergence or progression of AF and associated cardiovascular disease, as well as the initiation of active rhythm control ± anticoagulation to prevent AF-related morbidity and mortality, including stroke and heart failure (HF). Intuitively, intervention early after AF onset would be beneficial since lifestyle and co-morbidity management, plus rhythm control and anticoagulation, are important contributors to improved outcomes in patients with established AF, but robust evidence is lacking for recent-onset AF. There is a delicate balance between achieving favourable outcomes such as preventing strokes, HF and AF progression vs the complications and potential adverse effects of interventions. Given the serious long-term consequences, innovative approaches are necessary to determine the value and risks of initiating active therapy very early in the course of AF. More data are needed to guide the best management of recent-onset AF, bearing AF burden in mind. Long-term studies using large national databases linked to electronic medical records and rhythm monitoring devices offer excellent opportunities. Shorter-term studies focusing on reducing AF burden to slow AF progression and studies focusing on outcomes such as HF could be used in both randomized clinical trials and observational cohort studies.

AbstractThe intricate role of the autonomic nervous system (ANS) in regulating cardiac physiology has long been recognized. Aberrant function of the ANS is central to the pathophysiology of cardiovascular diseases. It stands to reason, therefore, that neuroscience‐based cardiovascular therapeutics hold great promise in the treatment of cardiovascular diseases in humans. A decade after the inaugural edition, this White Paper reviews the current state of understanding of human cardiac neuroanatomy, neurophysiology and pathophysiology in specific disease conditions, autonomic testing, risk stratification, and neuromodulatory strategies to mitigate the progression of cardiovascular diseases. image

Background: Atrioventricular (AV) conduction ablation has been achieved by targeting the area of penetration of the conduction axis as defined by recording a His bundle potential. Ablation of the His bundle may reduce the possibility of a robust junctional escape rhythm. It was hypothesised that specific AV nodal ablation is feasible and safe. Methods: The anatomical position of the AV node in relation to the site of penetration of the conduction axis was identified as described in dissections and histological sections of human hearts. Radiofrequency (RF) ablation was accomplished based on the anatomical criteria. Results: Specific anatomical ablation of the AV node was attempted in 72 patients. Successful AV nodal ablation was accomplished in 63 patients (87.5%), following 60 minutes (IQR 50–70 minutes) of procedure time, 3.4 minutes (IQR 2.4–5.5 minutes) of fluoroscopy time, and delivery of 4 (IQR 3–6) RF lesions. Αn escape rhythm was present in 45 patients (71%), and the QRS complex was similar to that before ablation in all 45 patients. Atropine was administered in six patients after the 10-min waiting period and did not result in restoration of conduction. In nine patients, AV conduction could not be interrupted, and AV block was achieved with ablation of the His after delivery of 12 (IQR 8–15) RF lesions. No cases of sudden death were encountered, and all patients had persistent AV block during a median 10.5 months (IQR 5–14 months) of follow-up. Conclusion: Anatomical ablation of the AV node is feasible and safe, and results in an escape rhythm similar to that before ablation.

Introduction: Incident cardiac arrhythmias are common in hospitalized COVID-19 patients, but the impact of a second incident cardiac arrhythmia during hospitalization on clinical outcomes remain unclear. Hypothesis: The aim of this study was to assess the frequency and prognostic implications of a second incident arrhythmia in hospitalized COVID-19 patients over the pandemic course till vaccine availability. Methods: The multicenter COVID-RHYTHM Registry enrolled hospitalized COVID-19 patients from 3/8/2020 to 1/24/2021. Cardiac arrhythmia included documented atrial fibrillation (AF), atrial flutter (AFL), ventricular tachycardia (VT), severe sinus bradycardia (<40 bpm) or AV block. Outcomes were compared between patients with single vs. more than one incident arrhythmias adjusting for baseline variables. Results: Of 6299 hospitalized COVID-19 patients, 4398 had an had an incident cardiac arrhythmia during hospitalization, of which 822 (19%) had a second incident arrhythmia. Those with >1 incident arrhythmia had a higher baseline prevalence of heart failure, chronic kidney disease, coronary artery disease and sleep apnea (Table). Those with >1 incident arrhythmia had higher in-hospital mortality, need for ICU admission and need for rehab upon discharge. Length of stay was similar between the groups. Conclusions: In hospitalized COVID-19 patients with incident cardiac arrhythmias, a second incident arrhythmia during hospitalization was seen in 19%. Having >1 incident arrhythmia was associated with increased need for ICU admission and reduced survival.

Introduction: There is a lack of data on the impact of sex on the outcomes of patients with heart failure (HF) undergoing atrial fibrillation (AF) ablation. Hypothesis: We hypothesized that outcomes of patients with HF undergoing AF ablation differ between males and females and tested this hypothesis using data from a nationally representative sample of the US population. Methods: The National Readmissions Database (NRD) was analyzed from 2016-2019 to identify patients ≥ 18 years old undergoing AF ablation. Patients were then divided into two cohorts based on their sex. A multivariable logistic regression model was used to adjust for confounders. Results: A total of 21,439 patients with HF underwent AF ablation between 2016-2019, of which 8,103 had heart failure with preserved ejection fraction (HFpEF) [64.8% were females], and 13,336 had heart failure with reduced ejection fraction (HFrEF) [38.4% were females]. Crude outcomes are shown in Figure 1. After multivariate adjustment, among patients with HFrEF, females had a longer length of stay (adjusted mean difference (aMD): 0.55 (0.16-0.93) days longer, p<0.01) along with lower odds of routine home discharge (adjusted odds ratio (aOR):0.62; 95% confidence interval (CI):0.55-0.70; p<0.01). Females had similar odds of in-hospital mortality, procedural complications, and 30-day/ 180-day all-cause, heart failure, and arrhythmia-related readmissions as compared to males. Among patients with HFpEF, females had higher odds of 30-day (aOR: 1.91; 95% CI: 1.24-2.93; p<0.01) and 180-day heart failure readmissions (aOR: 1.53; 95% CI: 1.04-2.28; p=0.03) along with lower odds of routine home discharge (aOR:0.67; 95% CI: 0.57-0.78; p<0.01), as compared to males. Conclusion: In conclusion, our results show that females with HFrEF undergoing AF ablation have similar odds of in-hospital/30-day/180-day outcomes whereas females with HFpEF have higher odds of 30-day/180-day HF readmissions, as compared to males.

Introduction: There is a lack of data on procedural safety and outcomes in patients with rheumatic mitral valve disease (RMVD) undergoing atrial fibrillation (AF) ablation. Hypothesis: We hypothesized that the presence of RMVD may affect the outcomes of patients undergoing AF ablation and tested this hypothesis using data from a large, nationally representative sample of the US population. Methods: The National Readmissions Database (NRD) was analyzed from 2016-2019 to identify patients ≥ 18 years old undergoing AF ablation. Patients with RMVD were then identified by using ICD-10 CM codes. A multivariable logistic regression model was used to adjust for confounders. Results: Our cohort included 50,728 weighted AF ablation procedures, of which 3,500 (6.9%) patients had RMVD. Patients with RMVD were older at the time of catheter ablation, with a significantly higher percentage of females, less likely to have paroxysmal AF, and had a higher burden of comorbidities including congestive heart failure, renal failure, and hypertension. On multivariable analysis, the presence of RMVD was associated with higher odds of cardiovascular complications (adjusted odds ratio [aOR] 1.28; 95% confidence interval [CI]: 1.12-1.47; p<0.01) with no difference in the odds of in-hospital mortality or other periprocedural outcomes. Also, RMVD was associated with longer length of stay (adjusted mean difference: +1.06; 95% CI: +0.67 - +1.45; p<0.01) days and lower odds of routine home discharge (aOR:0.77; 95% CI: 0.69-0.87; p<0.01). There was no difference in the odds of 30-day or 180-day all-cause, AF-related, or atrial flutter-related readmissions in patients with RMVD vs. no RMVD (Figure 1). Conclusion: In conclusion, patients with RMVD undergoing AF ablation have higher odds of periprocedural cardiovascular complications with similar odds of 30-day and 180-day all-cause and AF-related readmissions

Introduction: There is limited data on how psychosocial risk factors (PSRFs) affect the outcomes of patients undergoing atrial fibrillation (AF) ablation. Hypothesis: We hypothesized that the presence of PSRFs affects the outcomes of AF ablation and tested this hypothesis using a nationally representative sample of the US population. Methods: The National Readmissions Database (NRD) was analyzed from 2016-2019 to identify patients ≥ 18 years old undergoing AF ablation. Patients were divided into two cohorts based on the presence or absence of ≥1 PSRF. PSRFs were divided into 5 domains including limited cognitive understanding, substance use, psychiatric disease, low socioeconomic status, and uninsured status. A multivariable logistic regression model was utilized to adjust for confounders. Results: Our cohort included 50,623 AF ablation procedures, of which 21,363 (42.2%) had ≥ 1 PSRF. On multivariable analysis, the presence of ≥ 1 PSRF was associated with higher odds of cardiovascular complications (adjusted odds ratio [aOR] 1.11; 95% confidence interval [CI]: 1.02-1.22; p=0.02), peripheral vascular complications (aOR:1.18; 95% CI: 1.01-1.38; p=0.04), pulmonary complications (aOR:1.16; 95% CI: 1.05-1.29; p<0.01) and neurological complications (aOR:1.42; 95% CI: 1.12-1.78; p<0.01), along with higher odds of 30-day all-cause readmissions (aOR:1.30; 95% CI: 1.19-1.43; p<0.01) and atrial fibrillation/flutter related readmissions (aOR:1.27; 95% CI: 1.08-1.50; p<0.01), 90-day all-cause readmissions (aOR:1.30; 95% CI: 1.20-1.40; p<0.01) and atrial fibrillation/flutter related readmissions (aOR:1.22; 95% CI: 1.06-1.41; p<0.01), and 180-day all-cause readmissions (aOR:1.35; 95% CI: 1.24-1.45; p<0.01) (Figure 1). Conclusion: In conclusion, our data suggest an association between PSRFs and worse in-hospital outcomes along with increased all-cause and arrhythmia-related readmissions in patients undergoing AF ablation.

Abstract Background Obesity is associated with an increased risk of developing recurrent atrial fibrillation (AF) after catheter ablation (CA). However, the current data on weight loss interventions show inconsistent results in preventing the recurrence of AF after CA. Methods We conducted a systematic search in MEDLINE and EMBASE to identify studies that reported the outcome of recurrence of AF after CA in obese patients undergoing weight interventions. The subgroup analysis included: (1) Weight loss versus no weight loss, (2) >10% weight loss versus <10% weight loss, (3) <10% weight loss versus no weight loss, (4) Follow‐up <12 months, and (5) Follow‐up >12 months after CA. Mantel–Haenszel risk ratios with a 95% confidence interval (CI) were calculated using a random effects model and for heterogeneity, I 2 statistics were reported. Results A total of 10 studies (one randomized controlled trial and nine observational studies) comprising 1851 patients were included. The recurrence of AF was numerically reduced in the weight loss group (34.5%) versus no weight loss group (58.2%), but no statistically significant difference was observed (risk ratio [RR] = 0.76; 95% CI: 0.49–1.18, p = .22). However, there was a statistically significant reduction in recurrence of AF with weight loss versus no weight loss at follow‐up >12 months after CA (RR = 0.47; 95% CI: 0.32–0.68, p < .0001). At follow‐up >12 months after CA, both >10% weight loss versus <10% weight loss (RR = 0.49; 95% CI: 0.31–0.80, p = .004) and <10% weight loss versus no weight loss (RR = 0.39; 95% CI: 0.31–0.49, p < .00001) were associated with a statistically significant reduction in recurrent AF. Conclusion In patients with AF undergoing CA, weight loss is associated with reducing recurrent AF at > 12 months after ablation and these benefits are consistently seen with both >10% and <10% weight loss. The benefits of weight loss in preventing recurrent AF after CA should be examined in larger studies with extended follow‐up duration.

AbstractThe association of psychosocial risk factors with cardiovascular disease is well‐established, and there is a growing recognition of their influence on atrial fibrillation (AF) . A recent National Heart, Lung, and Blood Institute workshop called for transforming AF research to integrate social determinants of health. There is limited data examining the impact of psychosocial risk factors (PSRFs) on outcomes in patients with an established diagnosis of AF. Catheter ablation for AF has been shown to improve arrhythmia burden and quality of life compared with medical treatment alone. It is unknown how PSRFs affect clinical outcomes in patients undergoing AF ablation. It is important to understand this relationship, especially given the increasing adoption of catheter ablation in clinical practice.