Kewcharoen, Jakrin

AbstractIntroductionBrugada syndrome is an inherited arrhythmic disease associated with major arrhythmic events (MAE). The importance of primary prevention of sudden cardiac death (SCD) in Brugada syndrome is well recognized; however, ventricular arrhythmia risk stratification remains challenging and controversial. We aimed to assess the association of type of syncope with MAE via systematic review and meta‐analysis.MethodsWe comprehensively searched the databases of MEDLINE and EMBASE from inception to December 2021. Included studies were cohort (prospective or retrospective) studies that reported the types of syncope (cardiac, unexplained, vasovagal, and undifferentiated) and MAE. Data from each study were combined using the random‐effects, generic inverse variance method of DerSimonian and Laird to calculate the odds ratio (OR) and 95% confidence intervals (CIs).ResultsSeventeen studies from 2005 to 2019 were included in this meta‐analysis involving 4355 Brugada syndrome patients. Overall, syncope was significantly associated with an increased risk of MAE in Brugada syndrome (OR = 3.90, 95% CI: 2.22–6.85, p < .001, I2 = 76.0%). By syncope type, cardiac (OR = 4.48, 95% CI: 2.87–7.01, p < .001, I2 = 0.0%) and unexplained (OR = 4.71, 95% CI: 1.34–16.57, p = .016, I2 = 37.3%) syncope was significantly associated with increased risk of MAE in Brugada syndrome. Vasovagal (OR = 2.90, 95% CI: 0.09–98.45, p = .554, I2 = 70.9%) and undifferentiated syncope (OR = 2.01, 95% CI: 1.00–4.03, p = .050, I2 = 64.6%, respectively) were not.ConclusionOur study demonstrated that cardiac and unexplained syncope was associated with MAE risk in Brugada syndrome populations but not in vasovagal syncope and undifferentiated syncope. Unexplained syncope is associated with a similar increased risk of MAE compared to cardiac syncope.

AbstractBackgroundHigh‐power short‐duration (HPSD) atrial fibrillation (AF) ablation with a power of 40–50 W was proved to be safe and effective. Very high‐power short‐duration (vHPSD) AF ablation is a novel method using >50 W to obtain more durable AF ablation. This study aimed to evaluate the efficacy and safety of vHPSD ablation compared with HPSD ablation and conventional power ablation.MethodsA literature search for studies that reported AF ablation outcomes, including short‐term freedom from atrial arrhythmia, first‐pass isolation (FPI) rate, procedure time, and major complications, was conducted utilizing MEDLINE, EMBASE, and Cochrane databases. All relevant studies were included in this analysis. A random‐effects model of network meta‐analysis and surface under cumulative ranking curve (SUCRA) were used to rank the treatment for all outcomes.ResultsA total of 29 studies with 9721 patients were included in the analysis. According to the SUCRA analysis, HPSD ablation had the highest probability of maintaining sinus rhythm. Point estimation showed an odds ratio of 1.5 (95% confidence interval [CI]: 1.2–1.9) between HPSD ablation and conventional power ablation and an odds ratio of 1.3 (95% CI: 0.78–2.2) between vHPSD ablation and conventional power ablation. While the odds ratio of FPI between HPSD ablation and conventional power ablation was 3.6 (95% CI: 1.5–8.9), the odds ratio between vHPSD ablation and conventional power ablation was 2.2 (95% CI: 0.61–8.6). The procedure times of vHPSD and HPSD ablations were comparable and, therefore, shorter than that of conventional power ablation. Major complications were low in all techniques.ConclusionvHPSD ablation did not yield higher efficacy than HPSD ablation and conventional power ablation. With the safety concern, vHPSD ablation outcomes were comparable with those of other techniques.

AbstractIntroductionAtrial fibrillation (AF) is the most common cardiac arrhythmia with a high stroke and mortality rate. The video‐assisted thoracoscopic radiofrequency pulmonary vein ablation is a treatment option for patients who fail catheter ablation. Randomized data comparing surgical versus catheter ablation are limited. We performed a meta‐analysis of randomized control trials to explore the outcome efficacy between surgical and catheter radiofrequency pulmonary vein ablation in patients with AF.MethodsWe comprehensively searched the databases of MEDLINE and EMBASE from inception to December 2020. Included studies were published randomized control trials that compared video‐assisted thoracoscopic and catheter radiofrequency pulmonary vein ablation. Data from each study were combined using the fixed‐effects, generic inverse variance method of DerSimonian, and Laird to calculate odds ratios and 95% confidence intervals.ResultsSix studies from November 2013 to 2020 were included in this meta‐analysis involving 511 AF patients (79% paroxysmal) with 263 catheter ablation (mean age 56 ± 3 years) and 248 surgical ablations (mean age 52 ± 4 years). Catheter ablation was associated with increased atrial arrhythmias recurrence when compared to surgical ablation (pooled relative risk = 1.85, 95% confidence interval: 1.44−2.39, p < .001, I2 = 0.0%) but associated with less total major adverse events (pooled relative risk = 0.29, 95% confidence interval: 0.16−0.53, p < .001, I2 = 0.0%). In subgroup analysis, catheter ablation was associated with increased AF recurrence in refractory paroxysmal AF when compared to surgical ablation (pooled relative risk = 2.47, 95% confidence interval: 1.31−4.65, p = .005, I2 = 0.0%) but not in persistent AF (relative risk = 1.09, 95% confidence interval: 0.60−2.0, p = .773).ConclusionCatheter ablation was associated with higher atrial arrhythmia recurrence when compared with surgical ablation. However, our study suggests that the benefit of surgical ablation in patients with persistent AF is unclear. More studies and alternative ablation strategies investigation in persistent AF are warranted.

AbstractIntroductionAtrial fibrillation (AF) ablation is increasingly performed worldwide. As comfort with AF ablation increases, the procedure is increasingly used in patients that are older and in those with more comorbidities. However, it is not well established whether AF ablation in the elderly, especially those >75 years old, has comparable safety and efficacy to younger populations.ObjectiveTo compare the efficacy and safety profiles in patients older than 75 years undergoing AF ablation with younger patients.MethodsDatabases from EMBASE, Medline, PubMed, and Cochrane, were searched from inception through September 2021. Studies that compared the success rates in AF catheter ablation and all complications rates between patients who were older vs under 75 years were included. Effect estimates from the individual studies were extracted and combined using random effect, generic inverse variance method of DerSimonian and Laird.ResultsTwenty‐seven observational studies were included in the analysis consisting of 363,542 patients who underwent AF ablation. Comparing patients older than 75 years old to younger patients, there was no difference in the success of ablation rates between elderly and younger patients (pooled OR 0.85: 95% CI:0.69–1.05, p = .131). On the other hand, AF ablation in the elderly was associated with higher complication rates (pooled OR 1.42: 95% CI:1.21–1.68, p < .001).ConclusionAs AF ablation is expanded to elderly populations, our study found that AF ablation success rates were similar in both elderly and younger patients. However, older patients experience higher rates of complications that should be considered when offering the procedure and as a means to improve outcomes with future innovations.

AbstractBackgroundPosterior wall isolation (PWI) is an emerging approach in atrial fibrillation (AF) ablation, yet its efficacy remains controversial. This is the first meta‐analysis of randomized controlled trials (RCT) to evaluate the efficacy of PWI in AF ablation.ObjectiveTo assess the efficacy of PWI in reducing atrial arrhythmia recurrence following initial AF ablation at long‐term follow‐ups when compared to conventional methods.MethodsWe conducted a literature search from inception through September 2021 in EMBASE and MEDLINE databases. We included RCTs that compared outcomes in PWI and conventional approaches of AF ablation. Data from each study were combined using the random‐effects, generic inverse variance method of DerSimonian and Laird to calculate odds ratio (OR), and 95% confidence interval (CI).ResultsEight RCT from 2009 to 2020, including 1024 AF patients, were included. PWI did not decrease overall atrial arrhythmias recurrence (RR 0.96, 95% CI:0.88–1.05, I2 = 31.6%, p‐value 0.393). However, the pooled analysis showed a significant decrease in AF recurrence in PWI compared to controlled approaches (RR 0.88, 95% CI:0.81–0.96, I2 = 48.2%, p‐value .004). In the subgroup analysis, PWI significantly decreased AF recurrence in the studies that included only persistent AF (RR = 0.89, 95% CI:0.80–0.98, I2 = 65.2%, p‐value .014). PWI significantly decreased AF recurrence when compared to PVI with roof line (RR 0.84, 95% CI 0.74–0.95, I2 0.00%, p‐value .008).ConclusionOur study suggests that adding PWI significantly decreased AF recurrence in patients with persistent AF compared to controlled approaches. It highlights the importance of considering PWI during the initial procedure in this patient population.

AbstractBackgroundIn the modern era, atrial fibrillation (AF) ablation trend has been shifted toward same‐day discharge (SDD), from a traditional overnight stay. Yet, recent studies have not well stated the safety profiles which remained poor‐understood and dispersed. We hence performed systematic review and meta‐analysis to assess the adverse outcomes of SDD in comparison with an overnight stay.MethodsDatabases were searched through January 2021. Effect estimates from the individual studies were extracted and combined using random‐effects, generic inverse variance method of der Simonian and Laird. The primary outcomes included total cumulative complications and immediate complications following AF ablation.ResultsTen observational studies were met our inclusion criteria, comprising of total population of 11,660 patients, with SDD 51.3%. For total cumulative complications, there were no differences observed between SDD and overnight stay (5.2% vs. 6.2%: pooled OR 0.77: 95% CI 0.55–1.08, p = .13 with I2 = 27.1%). In addition, comparable immediate complications were also demonstrated (5.2 % vs. 4.3: pooled OR 1.08: 95% CI 0.72–1.62, p = .718, with I2 = 37.3 %).ConclusionOur study suggested that SDD had similar complication rates, both total cumulative and immediate outcomes, compared with overnight stay in selected patients following AF ablation. Nevertheless, randomized control trials are warranted to validate the findings.

AbstractBackgroundRadiofrequency catheter ablation for cardiac arrhythmias has traditionally been guided by fluoroscopy. Fluoroscopy exposes the patient, operator, and staff to ionizing radiation which has no safe dose void of stochastic and deterministic biologic risks. Zero fluoroscopy (ZF) approaches for catheter ablation have been advocated to eliminate these risks. We conducted a meta‐analysis comparing acute procedure success, recurrence‐free survival, complications, and procedure times between the approaches.MethodsWe conducted a literature search from inception through December 2020 in the databases of EMBASE and MEDLINE. We included randomized controlled trials and cohorts that compared the outcomes of interest in ZF and conventional/low fluoroscopy (CF/LF) approaches. The outcomes sought were acute procedure success, recurrence‐free survival, complications, and procedure times. Effect estimates were combined, using the random‐effects, generic inverse variance method of DerSimonian and Laird.ResultsSixteen studies from 2013 to 2020, including 6052 patients (2219 ZF, 3833 CF/LF) were included. There were no significant differences in acute procedure success rate (odds ratio [OR]: 1.10, 95% confidence interval [CI]: 0.75–1.59), recurrence‐free survival (OR: 1.08, 95% CI: 0.78–1.49), periprocedural complication rate (OR: 0.72, 95% CI: 0.45–1.16), or total procedure time (weighted mean difference 2.32 min, 95% CI: −2.85–7.50) between ZF and CF/LF approaches, respectively. Overall, only 1.26% of patients crossed over from ZF to CF/LF arm.ConclusionsPeriprocedural and postprocedural outcomes with a ZF approach compared favorably with traditional fluoroscopic guidance without increasing procedural times. As comfort with ZF grows, coupled with evolving mapping technologies, this method has potential to become the standard approach for catheter ablation.

Background Brugada syndrome is an inherited cardiac channelopathy associated with major arrhythmic events (MAEs). The presence of a positive family history of sudden cardiac death (SCD) as a risk predictor of MAE remains controversial. We aimed to examine the association between family history of SCD and MAEs stratified by age of SCD with a systematic review and meta‐analysis. Methods and Results We searched the databases of MEDLINE and EMBASE from January 1992 to January 2020. Data from each study were combined using the random‐effects model. Fitted metaregression was performed to evaluate the association between the age of SCD in families and the risk of MAE. Twenty‐two studies from 2004 to 2019 were included in this meta‐analysis involving 3386 patients with Brugada syndrome. The overall family history of SCD was not associated with increased risk of MAE in Brugada syndrome (pooled odds ratio [OR], 1.11; 95% CI, 0.82–1.51; P =0.489, I 2 =45.0%). However, a history of SCD in family members of age younger than 40 years of age did increase the risk of MAE by ≈2‐fold (pooled OR, 2.03; 95% CI, 1.11–3.73; P =0.022, I 2 =0.0%). When stratified by the age of cut point at 50, 45, 40, and 35 years old, a history of SCD in younger family member was significantly associated with a higher risk of MAE (pooled OR, 0.49, 1.30, 1.51, and 2.97, respectively; P =0.046). Conclusions A history of SCD among family members of age younger than 40 years was associated with a higher risk of MAE.

AbstractIntroductionBrugada syndrome (BrS) is associated with ventricular arrhythmia leading to sudden cardiac death. Risk stratification is challenging, as major arrhythmic events (MAEs) are rare. We assessed the utility of drug challenge testing in BrS by a systematic review and meta‐analysis.Methods and ResultsWe comprehensively searched the databases of MEDLINE and EMBASE from inception to May 2019. Included studies compared the incidence of MAE between spontaneous and drug challenge–induced Type 1. Mixed‐effects Poisson regression was used to calculate the incidence rate ratio (IRR). Eighteen studies from 2006 to 2018 were included (4099 patients, mean follow‐up: 4.5 years). Pooled annual incidences of MAE in spontaneous, drug challenge induced (regardless of symptoms), asymptomatic drug challenge induced, and symptomatic drug challenge–induced Type 1 were 23.8 (95% confidence interval [CI]: 19.8–27.8), 6.5 (95% CI: 3.9–9.1), 2.1 (95% CI: −0.3 to 4.4), and 19.6 (95% CI: 9.9–29.3) per 1000 person‐years, respectively. The incidence of MAE between symptomatic drug challenge induced and asymptomatic spontaneous Type 1 was not statistically different (IRR = 1.0; 95% CI: 0.6–1.7).ConclusionsThe incidence of MAE in drug challenge–induced Type 1 in asymptomatic patients is low. The incidence of MAE between symptomatic drug challenge induced and asymptomatic spontaneous Type 1 was similar.