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Background/aims: The SAMe-TT2R2 score is used for assessing anticoagulation control (AC) quality with warfarin. However, it is hard to apply SAMe-TT2R2 score in Asian patients with atrial fibrillation (AF), because it has not been proven in those populations. This study aimed to validate the SAMe-TT2R2 score in Asian patients with AF and suggest a modified SAMe- TT2R2 score for this population., Methods: We analyzed 710 Korean patients with AF who were using warfarin. The AC quality was assessed as the mean time in therapeutic range (TTR). Each component of SAMe-TT2R2 score was evaluated for the relationship with AC. Further clinical factors that predict AC were analyzed. Identified factors were re-assorted and constructed as SA2Me-TTR scoring system., Results: Of the components of the SAMe-TT2R2 score, female, age, and rhythm control were associated with AC. Heart failure and renal insufficiency were newly identified factors associated with AC. The modified SA2Me-TTR score was reconstructed with the relevant risk factors (S, female gender, 1 point; A, age < 60 yr, 2 points; Me, medical history of heart failure, 1 point; T, treatment for rhythm control, 1 point; T, history of stroke or transient ischemic attack, 1 point; R, renal insufficiency, 1 point). The modified SA2Me-TTR score demonstrated an excellent relationship with the grading of AC. The modified SA2Me-TTR score ≤ 1 identified patients with good AC (hazard ratio 2.46, 95% CI 1.75-3.47)., Conclusion: The modified SA2Me-TTR score was useful for guiding oral anticoagulants selection in Asian patients with AF.

Anticoagulation with warfarin in Asian patients with atrial fibrillation (AF) often has been decreased as an international normalized ratio (INR) of prothrombin time 1.6-2.6 due to fear of bleeding, although universal criteria recommend an INR of 2.0-3.0. In this randomized, open-label trial, low-intensity anticoagulation (INR 1.6-2.6) was compared with standard-intensity anticoagulation (INR 2.0-3.0) with warfarin. A total 616 patients with AF and at least 1 risk factor for stroke were randomized to low-intensity anticoagulation (n = 308) and standard-intensity anticoagulation (n = 308) groups. The intention-to-treat analysis was performed to determine differences. The baseline characteristics of the two groups were comparable. New-onset stroke occurred in 2 patients (0.44% per year) in the low-intensity group and 5 patients (1.05% per year) in the standard-intensity group (HR 0.42, 95% CI 0.08-2.15). Major bleeding occurred in 4 patients (0.89% per year) in the low-intensity group and 5 patients (1.06% per year) in the standard-intensity group (HR 0.84, 95% CI 0.22-3.11). The rate of the net clinical outcome (composite of stroke, systemic embolism, major bleeding, and death) was 1.33% per year in the low-intensity group compared with 2.12% per year in the standard-intensity group (HR 0.63, 95% CI 0.23-1.72). In Asian patients with AF, clinical outcomes were not different between low-intensity and standard-intensity anticoagulation with warfarin.

Background: Anticoagulants are the standard therapy for patients with atrial fibrillation (AF) and antiplatelet therapy for those with coronary artery disease (CAD). However, compelling clinical evidence is still lacking regarding the long-term maintenance strategy with the combination of anticoagulant and antiplatelet drugs in patients with AF and stable CAD., Design: The EPIC-CAD trial is an investigator-initiated, multicenter, open-label randomized trial comparing the safety and efficacy of 2 antithrombotic strategies in patients with high-risk AF (CHA 2 DS 2 -VASc score ≥ 2 points) and stable CAD (≥6 months after revascularization for stable angina or ≥12 months for acute coronary syndrome; or medical therapy alone). Patients (approximately N = 1,038) will be randomly assigned at a 1:1 ratio to (1) monotherapy with edoxaban (a non-vitamin K antagonist oral anticoagulant) or (2) combination therapy with edoxaban plus a single antiplatelet agent. The primary endpoint is the net composite outcome of death from any cause, stroke, systemic embolism, myocardial infarction, unplanned revascularization, and major or clinically relevant nonmajor bleeding at 1 year after randomization., Results: As of December 2021, approximately 901 patients had been randomly enrolled over 2 years at 18 major cardiac centers across South Korea. The completed enrollment is expected at the mid-term of 2022, and the primary results will be available by 2023., Conclusions: EPIC-CAD is a large-scale, multicenter, pragmatic design trial, which will provide valuable clinical insight into edoxaban-based long-term antithrombotic therapy in patients with high-risk AF and stable CAD., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation (AF) has been increasing. Accordingly, the combined use of antiplatelet agents (APT) and NOAC therapy is commonly encountered in clinical practice. The purpose of this study was to compare the clinical outcomes between combination therapy (NOAC and APT) vs. monotherapy (NOAC only) in patients with AF., Methods: We retrospectively analyzed patients who were prescribed NOACs between January 2012 and December 2016. The primary outcome was major bleeding and any bleeding events, and the secondary outcomes were stroke/systemic embolic (SE) events and major adverse cardiac events (MACE)., Results: Of the 1068 participants, there were 264 (24.7%) patients in the combination therapy group. The prevalence of diabetes ( p = 0.017) and history of stroke and transient ischemic attacks ( p < 0.001) was higher in the combination group than in the monotherapy group. During the mean 14.6 ± 9.8 months of follow-up, the incidence of any bleeding was significantly higher in the combination therapy group than in the monotherapy group ( p < 0.001). The rate of major bleeding, stroke/SE, and MACE between the two groups was similar. The rate of under-dosage NOAC prescriptions was higher in the combination therapy group than in the monotherapy group ( p = 0.024)., Conclusions: The combination therapy group had higher incidences of any bleeding events compared to the monotherapy in patients with appropriate dosing. However, there was no difference in stroke/SE, and MACE. The bleeding risk in AF patients taking the combination of NOACs and APT should be carefully evaluated., Competing Interests: The authors declare no conflict of interest., (© 2022 The Author(s). Published by IMR Press.)

Background: The left lateral ridge (LLR) is an important structure for ablation of atrial fibrillation (AF). This study assessed how the LLR shape is associated with the long-term outcomes of AF ablation and investigated the relationship with radiofrequency (RF) lesion formation., Methods and Results: Clinical study - we assessed multi-detector computed tomography (MDCT) images in 247 patients who underwent AF ablation. Patients were classified into two groups according to the shape of the LLR: Narrow LLR group (n = 116; 47%) and Wide LLR group (n = 131; 53%). After a follow-up period 475 ± 245 days, the AF-free rate was significantly higher in the wide LLR than Narrow LLR group (83.2% vs. 62.9%, p = 0.0004). A multivariate analysis showed that the shape of the LLR was an independent predictor of AF recurrence after ablation (hazard ratio 2.58; 95% confidential interval = 1.48-4.51, p = 0.001). Experimental study - Two types of the ridge models were made with porcine atrial tissues: "Narrow ridge(4.2 ± 0.9 mm)" and "Wide ridge(9.7 ± 1.8 mm)" RF ablation was performed on each ridge model using a contact force (CF)-sensing catheter. The mean CF and the RF lesion volume of the narrow ridge were significantly less than those of the wide ridge model (5.42 ± 3.13 g vs. 10.37 ± 3.98 g, p = 0.001; 19.8 ± 9.9 mm 3 vs. 44.2 ± 13.6 mm 3 , p < 0.001, respectively)., Conclusions: AF recurrence after ablation was more frequent in patients with a narrow LLR. LLR shape as assessed using MDCT is associated with long-term outcomes after AF ablation. CF and lesion formation data using the porcine atrial tissue model support our clinical results., Competing Interests: Declaration of Competing Interest The authors have no financial conflicts of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Patients with mitral stenosis and atrial fibrillation (AF) require anticoagulation for stroke prevention. Thus far, all studies on direct oral anticoagulants (DOACs) have excluded patients with moderate to severe mitral stenosis., Objectives: The aim of this study was to validate the efficacy of DOACs in patients with mitral stenosis., Methods: The study population was enrolled from the Health Insurance Review and Assessment Service (HIRA) database in the Republic of Korea, and it included patients who were diagnosed with mitral stenosis and AF and either were prescribed DOACs for off-label use or received conventional treatment with warfarin. The primary efficacy endpoint was ischemic strokes or systemic embolisms, and the safety outcome was intracranial hemorrhage., Results: A total of 2,230 patients (mean age 69.7 ± 10.5 years; 682 [30.6%] males) were included in the present study. Thromboembolic events occurred at a rate of 2.22%/year in the DOAC group, and 4.19%/year in the warfarin group (adjusted hazard ratio for DOAC: 0.28; 95% confidence interval: 0.18 to 0.45). Intracranial hemorrhage occurred in 0.49% of the DOAC group and 0.93% of the warfarin group (adjusted hazard ratio for DOAC: 0.53; 95% confidence interval: 0.22 to 1.26)., Conclusions: In patients with AF accompanied with mitral stenosis, DOAC use is promising and hypothesis generating in preventing thromboembolism. Our results need to be replicated in a randomized trial., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: The presence of inducible atrial tachyarrhythmia after pulmonary vein isolation (PVI) during radiofrequency catheter ablation (RFCA) for persistent atrial fibrillation (AF) may indicate the necessity of further substrate modification, but the optimal ablation endpoint is unknown. We sought to assess the impact of procedural termination of inducible atrial tachyarrhythmia after PVI in comparison with continued atrial tachyarrhythmia after PVI., Methods: Among patients who underwent RFCA for persistent AF, we enrolled 93 patients who were in sinus rhythm after PVI and had inducible atrial tachyarrhythmia and 157 patients with continued atrial tachyarrhythmia after PVI. The impact of acute arrhythmia termination during further substrate modification on recurrence was compared between the two groups., Results: Acute termination was achieved in 51 (54.8%) patients in the induced arrhythmia group and 61 (38.9%) in the continued arrhythmia group. During a mean 35.8 months, acute termination did not significantly reduce arrhythmia recurrence in the induced arrhythmia group (HR 0.712, 95% CI 0.400-1.266, p = 0.247), while it was associated with improved outcome in the continued arrhythmia group (HR 0.590, 95% CI 0.355-0.979, p = 0.038). Acute termination of either induced atrial tachycardia (AT) or induced AF was not associated with improved procedure outcome. Among the continued arrhythmia group, the benefit of acute termination was statistically significant in AT (HR 0.329, 95% CI 0.108-0.997, p = 0.039), but not in AF (HR 0.704, 95% CI 0.396-1.253, p = 0.233) after PVI., Conclusions: Acute termination of induced rhythm is not a reliable ablation endpoint during substrate modification in patients with inducible arrhythmia after PVI.

Purpose: Several approaches were tried to achieve complete pulmonary vein isolation (PVI). The aims of this study were to (1) compare adenosine-induced PV conduction and exit conduction, (2) determine the adequate adenosine dose, and (3) investigate the correlation of dormant conduction and recurrence of atrial fibrillation (AF)., Methods: A total of 378 consecutive patients who underwent PVI from June 2012 to April 2015 were prospectively included (the de novo procedure in 318 (84.1 %) and a redo procedure in 60 (15.9 %)). After the exit block was assessed, 20 mg adenosine was injected into the left atrium. If dormant conduction was observed, 12 and 6 mg of adenosine were injected sequentially., Results: Exit conduction during PV pacing was observed in 34 patients (9 %), and dormant conduction was observed in 92 patients (24.3 %). Among them, 74 (80.4 %, 74/92) demonstrated dormant conduction without exit conduction and 16 (47.1 %, 16/34) showed exit conduction without dormant conduction. The 20-mg dose of adenosine had an additive yield in patients with dormant conduction, compared to that of 12 mg (93 %, 86/92) or 6 mg (80 %, 74/92). There was no significant difference in the recurrence rate regarding dormant conduction. The pattern of prevalence of reconnected origin during the redo procedure was similar to that of dormant conduction during the index procedure., Conclusions: There was a discrepancy between adenosine-induced PVI and exit block. Therefore, exit block test has additional value to verify latent incomplete PVI in conjunction with adenosine test. Furthermore, high-dose adenosine had an additive yield., Clinical Trial Registration: https://www.clinicaltrials.gov/ct2/show/NCT01932112.

Background: Early recurrence (ER) of atrial tachyarrhythmias during the first 3 months (blanking period) after atrial fibrillation ablation can be highly symptomatic, often requiring emergency treatment. Short-term steroid therapy may suppress ER during the blanking period., Methods and Results: We prospectively enrolled 138 patients who were randomly assigned to 2 groups (steroid group and control group). An intravenous bolus of 0.5 mg/kg of methylprednisolone for 2 days followed by 12 mg daily of oral methylprednisolone for 4 days was given to the steroid group patients. The primary end point was ER during the blanking period (3 months post ablation). During the blanking period, 51 of the 138 (37.0%) patients experienced ER after atrial fibrillation ablation. The steroid group had a lower rate of ER than the control group (15/64 [23.4%] versus 36/74 [48.6%], P=0.003). There was no difference between the 2 groups about late recurrence during a 24-month follow-up (log-rank test, P=0.918). In a multivariate analysis, short-term steroid therapy was independently associated with a lower rate of ER during the blanking period (adjusted OR, 0.45; 95% confidence interval, 0.25-0.83; P=0.01)., Conclusions: Periprocedural short-term moderate intensity steroid therapy reduces ER (≈3 months) after catheter ablation of atrial fibrillation. It is not effective in preventing late (3≈24 m) atrial fibrillation recurrence., Clinical Trial Registration: URL: www.who.int/ictrp; Unique identifier: KCT0000107., (© 2015 American Heart Association, Inc.)

Background: Prompt diagnosis and management of atrial tachyarrhythmias (ATAs) during catheter ablation of atrial fibrillation (AF) is still challenging., Methods and Results: In 88 patients undergoing catheter ablation of AF, 128 regular ATAs were induced or converted from AF. The coronary sinus activation time (CSAT) around the mitral annulus (MA) was measured as the difference in activation time between the most proximal and distal poles of the coronary sinus (CS) electrodes. Entrainment pacing was performed around the MA, roof area, or cavotricuspid isthmus (CTI) depending on the CSAT result. Mechanisms of tachycardias included macro-reentry around the MA (perimitral atrial flutter [PM-AFL], n=63), roof-dependent AFL (Roof-AFL, n=14), CTI-dependent AFL (CTI-AFL, n=25), and atrial tachycardia (AT, n=26). When the CSAT was ≥ 45 ms, the MA activation sequence was sequential, either proximal to distal or distal to proximal. When the CSAT was <45 ms, the MA activation sequence was mainly non-sequential with converging or diverging patterns. CSAT <45 ms was highly sensitive in ruling out PM-AFL from other left ATAs. When combined with PPI data from the MA, roof area or CTI, PM-, Roof-, CTI-AFL and AT was successfully differentiated with a high predictive accuracy., Conclusions: A diagnostic algorithm combining CSAT and entrainment pacing is helpful to assess the mechanism of ATAs during catheter ablation of AF.

Background: Current guidelines consider atrial fibrillation (AF) type as the prognostic factor for a recommendation of catheter ablation. We aimed to determine whether LA and LA appendage (LAA) volumes measured using multislice computed tomography (MSCT) were related to long-term outcomes in AF following radiofrequency catheter ablation (RFCA). Methods: We evaluated 152 consecutive patients with drug-refractory AF (median age, 55.8 ± 9.6 years), including 110 male patients, who underwent RFCA in a single center. All patients underwent MSCT imaging for anatomical assessment. The endpoint of this study was documented AF recurrence after RFCA. Results: The overall procedure success rate was 77.6% (n = 118) during a mean follow-up period of 12.6 months. The LA volume was significantly larger for those who experienced AF recurrence after RFCA than for the patients without recurrent AF after the procedure (153.8 ± 29.9 mL vs. 139.2 ± 34.1 mL, p = 0.025). However, LAA volumes were nearly equivalent between the patients with and without AF recurrence after RFCA (16.2 ± 6.3 mL and 14.7 ± 6.5 mL, respectively; p = 0.235). LA volume ≥ 153.2 mL was the optimal cutoff value for estimating AF recurrence after RFCA, with 94% sensitivity and 66% specificity. LA volume remained an independent predictor of both AF recurrence and permanent AF. Conclusions: LA volume as assessed by MSCT might be helpful for identifying patients likely to achieve successful AF ablation. LA volume ≥ 153.2 mL, but not LAA volume, showed good accuracy in predicting AF recurrence after RFCA. [ABSTRACT FROM AUTHOR]

Background: The use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation (AF) has been increasing. Accordingly, the combined use of antiplatelet agents (APT) and NOAC therapy is commonly encountered in clinical practice. The purpose of this study was to compare the clinical outcomes between combination therapy (NOAC and APT) vs. monotherapy (NOAC only) in patients with AF.Methods: We retrospectively analyzed patients who were prescribed NOACs between January 2012 and December 2016. The primary outcome was major bleeding and any bleeding events, and the secondary outcomes were stroke/systemic embolic (SE) events and major adverse cardiac events (MACE).Results: Of the 1068 participants, there were 264 (24.7%) patients in the combination therapy group. The prevalence of diabetes (p = 0.017) and history of stroke and transient ischemic attacks (p < 0.001) was higher in the combination group than in the monotherapy group. During the mean 14.6 ± 9.8 months of follow-up, the incidence of any bleeding was significantly higher in the combination therapy group than in the monotherapy group (p < 0.001). The rate of major bleeding, stroke/SE, and MACE between the two groups was similar. The rate of under-dosage NOAC prescriptions was higher in the combination therapy group than in the monotherapy group (p = 0.024).Conclusions: The combination therapy group had higher incidences of any bleeding events compared to the monotherapy in patients with appropriate dosing. However, there was no difference in stroke/SE, and MACE. The bleeding risk in AF patients taking the combination of NOACs and APT should be carefully evaluated. [ABSTRACT FROM AUTHOR]

Background: Early recurrence (ER) of atrial tachyarrhythmias during the first 3 months (blanking period) after atrial fibrillation ablation can be highly symptomatic, often requiring emergency treatment. Short-term steroid therapy may suppress ER during the blanking period.Methods and Results: We prospectively enrolled 138 patients who were randomly assigned to 2 groups (steroid group and control group). An intravenous bolus of 0.5 mg/kg of methylprednisolone for 2 days followed by 12 mg daily of oral methylprednisolone for 4 days was given to the steroid group patients. The primary end point was ER during the blanking period (3 months post ablation). During the blanking period, 51 of the 138 (37.0%) patients experienced ER after atrial fibrillation ablation. The steroid group had a lower rate of ER than the control group (15/64 [23.4%] versus 36/74 [48.6%], P=0.003). There was no difference between the 2 groups about late recurrence during a 24-month follow-up (log-rank test, P=0.918). In a multivariate analysis, short-term steroid therapy was independently associated with a lower rate of ER during the blanking period (adjusted OR, 0.45; 95% confidence interval, 0.25-0.83; P=0.01).Conclusions: Periprocedural short-term moderate intensity steroid therapy reduces ER (≈3 months) after catheter ablation of atrial fibrillation. It is not effective in preventing late (3≈24 m) atrial fibrillation recurrence.Clinical Trial Registration: URL: www.who.int/ictrp; Unique identifier: KCT0000107. [ABSTRACT FROM AUTHOR]