DeSimone, Christopher V.

Abstract Background Catheter ablation has emerged as the first-line therapy for management of ventricular tachycardia (VT) over the last decade. There is a reluctance for older patients to be referred for catheter ablation with concerns for complications and poor outcomes. Purpose The purpose of the study was to assess the safety and outcomes of catheter ablation for VT in patients more than 74 years of age in comparison to younger patients. Methods A single-center retrospective study of 200 procedures in 168 patients undergoing catheter ablation for scar-related VT was conducted. Data collected included demographics, comorbidities, medications, relevant laboratory abnormalities, electrocardiograms, Holter, device electrograms, structural data including echocardiograms and cardiac magnetic resonance imaging, detailed procedural characteristics, and outcomes. Results The mean age in the older cohort was 77.7 ± 3.7 years compared to 57.6 ± 13.1 years in the younger group (p < 0.01) [Figure 1]. The geriatric patients had more males (93.6% vs. 75.8%) and had greater proportion of comorbidities including congestive heart failure (89.4% vs. 66.7%), hypertension (91.5% & 56.9%), atrial arrhythmias (66.0% vs. 43.1%), chronic kidney disease (68.1% vs. 31.4%), prior myocardial infarction (53.2% vs. 24.2%), and stroke (21.3% vs. 8.5%). The older patients were on more antiarrhythmic drugs at baseline. During the procedure, the number of cases with VT induction and hemodynamic stability was similar in older and younger groups. In cases where VT was induced, the older patients had a greater number of VTs induced (2.7 ± 3.0 vs. 1.9 ± 1.8), with slower cycle lengths (454.9 ± 122.6 vs. 379.3 ± 108.1 milliseconds). There was no difference noted in the procedural complications between the two groups. Older patients were more likely to be discharged on antiarrhythmic medications (87.2% vs. 71.2%) and had higher long-term mortality (29.8% vs. 7.8%). The older group was less likely to have a repeat ablation procedure (8.5% vs 24.2%). There was no difference in long-term VT-free survival rates among the two groups [Figure 2]. Conclusion Patients more than 74 years of age undergoing catheter ablation for structural VT have a greater comorbidity burden but demonstrate similar procedural complications and VT-free survival rates, when compared to the younger cohort.Figure 1Figure 2

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.

AbstractThe discrimination of ventricular tachycardia (VT) versus supraventricular wide complex tachycardia (SWCT) via 12‐lead electrocardiogram (ECG) is crucial for achieving appropriate, high‐quality, and cost‐effective care in patients presenting with wide QRS complex tachycardia (WCT). Decades of rigorous research have brought forth an expanding arsenal of applicable manual algorithm methods for differentiating WCTs. However, these algorithms are limited by their heavy reliance on the ECG interpreter for their proper execution. Herein, we introduce the Mayo Clinic ventricular tachycardia calculator (MC‐VTcalc) as a novel generalizable, accurate, and easy‐to‐use means to estimate VT probability independent of ECG interpreter competency. The MC‐VTcalc, through the use of web‐based and mobile device platforms, only requires the entry of computerized measurements (i.e., QRS duration, QRS axis, and T‐wave axis) that are routinely displayed on standard 12‐lead ECG recordings.

Abstract Background Atrial fibrillation (AF) is common in hypertrophic cardiomyopathy (HCM). There is limited data regarding the outcomes of AF catheter ablation in HCM patients. In this study, we aimed to synthesize all available evidence on the effectiveness of ablation of AF in patients with HCM compared to those without HCM. Methods and results We systematically reviewed bibliographic databases to identify studies published through February 2023. We included cohort studies with available quantitative information on rates of recurrent atrial arrhythmias, anti-arrhythmic drug (AAD) therapy, and repeat ablation procedures after initial AF ablation in patients with vs without HCM. Estimates were combined using random-effects meta-analysis models and reported as risk ratios (RR) and 95% confidence intervals (CI). Eight studies were included in quantitative synthesis (262 HCM and 642 non-HCM patients). During median follow-up 13–54 months across studies, AF recurrence rates ranged from 13.3% to 92.9% in HCM and 7.6% to 58.8% in non-HCM patients. The pooled RR for recurrent atrial arrhythmia after the first AF ablation in HCM patients compared to non-HCM controls was 1.498 (95% CI = 1.305–1.720; P &lt; 0.001). During follow-up, HCM patients more often required AAD therapy (RR = 2.844; 95% CI = 1.713–4.856; P &lt; 0.001) and repeat AF ablation (RR = 1.544; 95% CI = 1.070–2.228; P = 0.02). The pooled RR for recurrent atrial arrhythmias after the last AF ablation was higher in patients with HCM than those without HCM (RR = 1.607; 95% CI = 1.235–2.090; P &lt; 0.001). Conclusions Compared to non-HCM patients, those with HCM had higher rates of recurrent atrial arrhythmias, AAD use, and need for repeat AF ablation after initial ablation of AF.

Abstract Background and Aims Colchicine is an anti-inflammatory drug that may prevent post-operative atrial fibrillation (POAF). The effect of this drug has been inconsistently shown in previous clinical trials. We aimed to compare the efficacy and safety of colchicine vs. placebo to prevent POAF in patients undergoing cardiac surgery. Methods and results A systematic search of EMBASE, MEDLINE, SCOPUS, ClinicalTrials.gov, and the Cochrane Library for randomized controlled trials (RCTs) was conducted from inception till April 2023. The primary outcome was the incidence of POAF after any cardiac surgery. The secondary outcome was the rate of drug discontinuation due to adverse events and adverse gastrointestinal events. Risk ratios (RR) were reported using the Mantel Haenszel method. A total of eight RCTs comprising 1885 patients were included. There was a statistically significant lower risk of developing POAF with colchicine vs. placebo (RR: 0.70; 95% CI: 0.59–0.82; P &lt; 0.01, I2 = 0%), and this effect persisted across different subgroups. There was a significantly higher risk of adverse gastrointestinal events (RR: 2.20; 95% CI: 1.38–3.51; P &lt; 0.01, I2 = 55%) with no difference in the risk of drug discontinuation in patients receiving colchicine vs. placebo (RR: 1.33; 95% CI: 0.93–1.89; P = 0.11, I2 = 0%). Conclusion This meta-analysis of eight RCTs shows that colchicine is effective at preventing POAF, with a significantly higher risk of adverse gastrointestinal events but no difference in the rate of drug discontinuation. Future studies are required to define the optimal duration and dose of colchicine for the prevention of POAF.

Introduction: Obesity is associated with a higher burden of atrial fibrillation (AF) and related complications. Hypothesis: Bariatric surgery in patients with AF is associated with a reduction in mortality and long-term complications at 1 year. Methods: Patients with AF who underwent bariatric surgery were identified by analyzing the nationwide readmission database and incorporating the validated ICD-10 CM codes from October 2015 to December 2019. We performed the propensity score matching to adjust the confounders and cox proportional hazard regression to generate hazard ratios. Moreover, we generated Kaplan Meier curves for time-to-event analysis. The primary endpoint was all-cause mortality at 1 year, whereas secondary endpoints were ischemic stroke, major bleeding, and AF readmission at 1 year. Results: Out of 892488 obese patients with AF, 18766 underwent bariatric surgery. After propensity score matching, 18764 patients were identified in each group. At 1-year, patients undergoing bariatric surgery had a significant reduction in mortality (2.18% vs. 2.73%, HR: 0.91, 95% CI: 0.85-0.96, p=0.001). Additionally, risk of ischemic stroke was also reduced (1.98% vs. 2.29%, HR: 0.91, 95% CI: 0.86-0.97, p=0.01), whereas no difference was noted in AF readmissions (4.02% vs. 3.34%, HR: 0.97, 95% CI: 0.92-1.04, p=0.49) and risk of major bleeding was increased (5.74% vs. 3.42%, HR: 1.17, 95% CI: 1.10-1.25, p<0.0001) at 1 year in AF patients with bariatric surgery. (Figure 1) Conclusions: Bariatric surgery in patients with AF was associated with a reduction in 1-year mortality and ischemic stroke. However, the risk of major bleeding was noted to be increased and no difference was noted in AF readmission at 1 year.

BACKGROUND: Differentiation of wide QRS complex tachycardias (WCTs) into ventricular tachycardia (VT) and supraventricular wide QRS tachycardia (SWCT) through 12-lead electrocardiogram (ECG) interpretation is one of the most critical yet challenging tasks in clinical practice. Recent research highlights novel automated methods that successfully diagnose WCTs. We sought to directly compare the diagnostic efficacy of these novel automated WCT differentiation methods (i.e., WCT Formula, VT Prediction Model, and WCT Formula II) to traditional ECG interpretation approaches (i.e., Brugada and Vereckei aVR algorithms). METHODS: A collection of paired WCT and baselined ECGs were retrospectively analyzed. Next, an electrophysiologist blindly and prospectively applied the Brugada and Vereckei aVR algorithms. Separately, computerized measurements were used to apply the three automated WCT differentiation methods. The diagnostic performance of each method was then evaluated. RESULTS: 213 WCTs (111 VT and 102 SWCT) from 105 patients were analyzed. The WCT Formula demonstrated superior overall accuracy (84.7% vs. 64.8%), specificity (86.2% vs. 35.3%), positive predictive value (PPV) (85.7% vs. 60.7%), and positive (+) likelihood ratio (LR) (6.06 vs. 1.42) compared to Vereckei aVR algorithm. Similarly, the WCT Formula attained higher specificity (86.2% vs. 61.8%), PPV (85.7% vs. 71.9%), and (+) LR (6.06 vs. 2.36) than the Brugada algorithm. The WCT Formula II demonstrated superior overall accuracy (89.2% vs. 64.8%), specificity (84.3 % vs. 35.3%), PPV (86.7% vs. 60.7%), and positive (+) LR (5.97 vs.1.42) compared to Vereckei aVR algorithm as well as higher specificity (84.3 % vs. 61.8 %), PPV (86.7% vs. 71.9%), and (+) LR (5.97 vs. 2.36) than the Brugada algorithm. The VT prediction model yielded superior specificity (79.4% vs. 35.3%), PPV (79.8 vs. 60.7%) and (+) LR (3.63 vs.1.42) compared to the Vereckei aVR algorithm but did not demonstrate superior diagnostic performance to the Brugada algorithm. CONCLUSIONS: Novel automated WCT differentiation methods achieved similar or superior diagnostic performance metrics compared to traditional ECG interpretation approaches.

Introduction: Patients with a history of inflammatory bowel disease (IBD) are at a higher risk of atrial fibrillation (AF). There is a lack of evidence supporting catheter ablation in this group and predictors of procedural outcomes are unknown. Hypothesis: We assessed the hypothesis that patients with a history of IBD have worse procedural outcomes with more peri-procedural complications, especially in those whose disease is less well controlled. Methods: A single-center 1:1 propensity matched study of patients with no history of IBD and patients with IBD who underwent primary AF catheter ablation from January 2010 to December 2021 was conducted. The primary outcome was procedural efficacy defined by clinical AF recurrence and repeat catheter ablation. The secondary outcome was an assessment of safety looking at eight peri-procedural events. Univariate and multivariate binary logistic regression analysis was conducted to determine predictors of AF recurrence. Results: Our cohort was comprised of 94 patients, 47 patients with a history of IBD (mean age 64.7 ± 6.4 years) and 47 patients with no history of IBD (66.7 ± 7.1 years). Both groups had similar echocardiographic, baseline, and arrhythmia characteristics. All patients underwent pulmonary vein isolation and procedural endpoints were ascertained in all patients. At one-year post-ablation, the study group was statistically more likely to develop AF recurrence (OR 2.38, 95% CI 1.09 - 4.86, p=0.03) but were equally likely to undergo repeat catheter ablation (OR 2.56, 95% CI 0.62 - 10.6, p=0.19). Procedural safety was statistically similar in both groups. Four patients in the study group and three patients in the control group developed subcutaneous hematomas at the site of instrumentation (p=0.70). Multivariate analysis found pre-procedural c-reactive protein (CRP) (OR 1.04, 95% CI 1.00 - 1.12) and AF diagnosis to ablation time (OR 1.15, 95% CI 1.03 - 1.24) were independent predictors of post-procedure AF recurrence. Conclusions: Our study suggests patients with IBD are at a higher risk of developing AF recurrence after catheter ablation. Multivariate analysis showed CRP and AF diagnosis to time to ablation were both independent risk factors.

Introduction: There is a variation in cardiovascular outcomes between rural and urban hospitals such as higher mortality for AF. Whether such a relationship exists for safety and outcomes of left atrial appendage occlusion (LAAO) device implantation is unknown. Hypothesis: We hypothesized that LAAO procedure in rural hospitals is associated with worse in-hospital outcomes. Methods: A cross-sectional examination of patients who were hospitalized for LAAO procedure was performed in the National Inpatient Sample between 2016 and 2019 to compare in-hospital outcomes in patients admitted to urban vs rural hospitals. ICD 10 PCS code 02L73DK was used to identify hospitalizations with LAAO procedure. The cohort was further stratified into rural and urban hospitals. Chi-square test and multivariate logistic regression were used to analyze the association and statistical analyses were performed using weighted values. Results: A total of 61,390 hospitalizations for LAAO procedures were identified during the study period. From these, 1185 (1.93%) hospitalizations occurred in rural hospitals. Baseline characteristics and inpatient outcomes are shown in Table 1. LAAO in rural hospitalizations was associated with significantly higher in-hospital mortality [OR 2.94 (1.17-7.14), p<0.001*]. This associated persisted even after adjusting for significant baseline characteristics [aOR 3.55 (1.42-8.84), p=0.006*). Conclusions: In-hospital mortality was significantly higher in patients undergoing LAAO in rural hospital. Further studies are needed to validate these findings in a prospective manner.