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Pre-excited atrial fibrillation (AF) is associated with increased risk of life-threatening events. However, at times, patients with pre-excited AF still repetitively suffer from hemodynamic disturbance, with resistance to acute treatments of antiarrhythmic therapy and cardioversion.To evaluate the feasibility in correcting hemodynamic disturbance, patients with pre-excited AF who underwent catheter ablation of accessory pathway as an emergency procedure, were retrospectively collected from two centers of China. The medical records of patients were analyzed and summarized in this case series.Five patients with pre-excited AF who received emergency catheter ablation of accessory pathway, were collected from two contributor centers and reported in this case series. All collected patients still repetitively suffered from hemodynamic disturbance induced by rapid anterograde conduction of AF via pathway, even guideline recommended acute interventions of intravenous antiarrhythmic therapy and cardioversion had been performed. Finally, as an emergency procedure, catheter ablation of accessory pathway was performed in collected patients. Correspondingly, the hemodynamic unstable status was greatly relieved. Meanwhile, all collected patients with high risk of pre-excited AF were combined with left-sided accessory pathway, with shortest RR interval of widened pre-excited QRS complex less than 250 ms. Thus, combination with left-sided pathway is proposed as an indicator for the increased risk of life-threatening events in patients with high risk of pre-excited AF.Emergency catheter ablation of accessory pathway is an effective option for the acute managements of patients with high risk of pre-excited AF in unstable hemodynamics, which is resistant to antiarrhythmic therapy and cardioversion.

Aims Catheter ablation (CA) is recommended for patients with atrial fibrillation (AF) after failure of antiarrhythmic drugs (AADs). The role of CA as ‘initial therapy’ for AF is to be determined. Methods and results Following PRISMA guideline an up-to-date pooled analysis of randomized data comparing ablation vs. AADs as first-line therapy for symptomatic AF was performed. The primary outcome was recurrence of atrial tachyarrhythmia. The secondary outcomes were improvement in quality-of-life (QoL) and major adverse events. A total of 997 patients from five randomized trials were enrolled (mean age 57.4 years, 68.6% male patients, 98% paroxysmal AF, mean follow-up 1.4 years). The baseline characteristics were similar between the ablation and AADs group. Overall pooled analysis showed that, as compared with AADs, CA as first-line therapy was associated with significantly higher freedom from arrhythmia recurrence (69% vs. 48%, odds ratio: 0.36, 95% confidence interval: 0.27–0.48, P Conclusions Catheter ablation as ‘initial therapy’ was superior to AADs in maintenance of sinus rhythm and improving QoL for patients with symptomatic paroxysmal AF, without increasing risk of serious adverse events.

Aims Anticoagulation for atrial fibrillation patients with liver disease represents a clinical dilemma. We sought to evaluate the efficacy/safety of different anticoagulation, i.e. vitamin K antagonist (VKA) and non-VKA oral anticoagulants (NOACs) in such patient group. Methods and results This was a pooled-analysis enrolling up-to-date clinical data. Two subsets: subset A (VKA vs. Non-Anticoagulation) and subset B (NOACs vs. VKA) were pre-specified. The study outcomes were ischaemic stroke (IS)/thromboembolism (TE), major bleeding (MB), intracranial bleeding (ICB), gastrointestinal bleeding (GIB), and all-cause mortality. A total of 20 042 patients’ data were analysed (subset A: N = 10 275, subset B: N = 9767). Overall mean age: 71 ± 11 years, mean CHA2DS2-VASc score: 4.0 ± 1.8, mean HAS-BLED score: 3.6 ± 1.2. The majority of the patients had Child-Pugh category (A-B). As compared with Non-Anticoagulation, VKA seemed to reduce the risk of IS/TE [odds ratio (OR): 0.60, P = 0.05], but heighten the risk of all-bleeding events including MB (OR: 2.81, P = 0.01), ICB (OR: 1.60, P = 0.01), and GIB (OR: 3.32, P = 0.01). When compared with VKA, NOACs had similar efficacy in reducing the risk of IS/TE (OR: 0.82, P = 0.64), significantly lower risk of MB (OR: 0.54, P = 0.0003) and ICB (OR: 0.35, P Conclusions VKA appears to reduce the risk of IS/TE but increase all-bleeding events. NOACs have similar effect in reducing the risk of IS/TE and have significantly lower risk of MB and ICB as compared with VKA. NOACs seem to be associated with better clinical outcome than VKA in patients with mild–moderate liver disease.

Background Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery, resulting in an increased risk of morbidity and longer hospital stay. Pharmacologic prophylaxis has been recommended to improve the outcome in patients at high risk of developing POAF after cardiac surgery. Several studies have applied the CHA2DS2-VASc (Congestive heart failure, Hypertension Age [≥65 = 1 point, ≥75 = 2 points], Diabetes, and Stroke/transient ischemic attack (2 points)–vascular disease [peripheral arterial disease, previous myocardial infarction, aortic atheroma]) score in the risk stratification of POAF but yielded contradicting results. This study aims to determine the association between CHA2DS2-VASc score and POAF and further to explore its discriminative ability for the prediction of POAF. Methods We systematically searched the Medline, Embase, Cochrane library, and other data sources with key terms “CHA2DS2-VASc,” “atrial fibrillation,” and “cardiac surgery.” Studies designed for CHA2DS2-VASc score in stratifying the risks of POAF in patients undergoing cardiac surgery were included. Statistical analyses were performed with R 3.5.1 and STATA 13.0. Results Seven hundred twenty-one studies were identified, of which 12 studies with 18,086 patients were finally included in our analysis. The CHA2DS2-VASc score was found to be an independent predictor of POAF after cardiac surgery (odds ratio, 1.46; 95% confidence interval [CI], 1.25-1.72) and exhibited a relatively strong specificity (0.70; 95% CI, 0.61-0.78) and sensitivity (0.72; 95% CI, 0.54-0.85) for predicting POAF. The bivariate model-based pooled area under the receiver operating curve was estimated to be 0.76 (95% CI, 0.72-0.79). Conclusions The CHA2DS2-VASc score has relatively good performance in predicting POAF after cardiac surgery and may help identify the patients at high risk of POAF.

This study evaluated the role of adjunctive left atrium posterior wall isolation (PWI) in preventing atrial fibrillation (AF) recurrence.The left atrium posterior wall is an arrhythmogenic substrate that contributes to the development of AF.This was an updated pooled analysis that included clinical data regarding PWI plus pulmonary vein isolation (PVI) in treating AF. The primary outcome was recurrence of atrial tachyarrhythmias.A total of 26 studies with 3,287 patients with AF (age 61.7 ± 10.8 years) were included. Mean follow-up was 15.2 ± 8.4 months. Procedural success to achieve PWI was 92.8%. In paroxysmal AF, adjunctive PWI did not reduce the recurrence of all atrial arrhythmias (P = 0.21) or AF (P = 0.37); however, in persistent AF, adjunctive PWI was associated with substantially lower recurrence of all atrial arrhythmias (risk ratio: 0.74; P 0.001) and AF (risk ratio: 0.67; P = 0.01), particularly when randomized data were included. Subgroup analyses based on meta-regression demonstrated that patients with older age, a larger left atrial diameter, and persistent AF benefited more significantly from the adjunctive PWI. Adjunctive PWI using either radiofrequency or a cryoballoon reduced AF recurrence, whereas using radiofrequency seemed to be associated with higher recurrence rate of atrial tachycardias and/or atrial flutter. Non-BOX adjunctive PWI rather than BOX PWI was associated with significantly lower recurrence of AF. The incidence of procedural adverse events between the PVI+PWI (3.2%) and PVI (2.8%) groups was low and similar. PVI+PWI needed longer ablation and/or procedural time but had similar fluoroscopy time.Adjunctive PWI can be achieved in most patients without compromising safety. Patients with persistent AF appear to benefit from this approach. The ablation technology and/or approach may affect the clinical outcome of PWI.

Aims The optimal treatment for patients with atrial fibrillation (AF) and heart failure (HF) has been a subject of debate for years. We aimed to evaluate the efficacy and safety of rhythm control strategy in patients with AF complicated with HF regarding hard clinical endpoints. Methods and results Up-to-date randomized data comparing rhythm control using antiarrhythmic drugs (AADs) vs. rate control (Subset A) or rhythm control using catheter ablation vs. medical therapy (Subset B) in AF and HF patients were pooled. The primary outcomes were all-cause mortality, re-hospitalization, stroke, and thromboembolic events. A total of 11 studies involving 3598 patients were enrolled (Subset A: 2486; Subset B: 1112). As compared with medical rate control, the AADs rhythm control was associated with similar all-cause mortality [odds ratio (OR): 0.96, P = 0.65], significantly higher rate of re-hospitalization (OR: 1.25, P = 0.01), and similar rate of stroke and thromboembolic events (OR: 0.91, P = 0.76,); however, as compared with medical therapy, catheter ablation rhythm control was associated with significantly lower all-cause mortality (OR: 0.51, P = 0.0003), reduced re-hospitalization rate (OR: 0.44, P = 0.003), similar rate of stroke events (OR: 0.59, P = 0.27), greater improvement in left ventricular ejection fraction [weighted mean difference (WMD): 6.8%, P = 0.0004], lower arrhythmia recurrence (29.6% vs. 80.1%, OR: 0.04, P Conclusion Catheter ablation as rhythm control strategy substantially improves survival rate, reduces re-hospitalization, increases the maintenance rate of sinus rhythm, contributes to preserve cardiac function, and improves quality of life for AF patients complicated with HF.

Objective This study was performed to observe the effect of radiofrequency catheter ablation (RFCA) in patients with paroxysmal atrial fibrillation (PAF) and to explore the risk factors for late recurrence of atrial fibrillation (LRAF) after a single RFCA session. Methods In this retrospective study, 243 patients with PAF underwent RFCA and were followed up regularly. Results At a median follow-up of 37 months after a single procedure, 60.5% of patients maintained sinus rhythm (SR), and at a median follow-up of 42 months after multiple procedures, 74.9% of patients maintained SR. The statistically significant risk factors for LRAF after a single RFCA session were the left atrial diameter (LAD), left inferior pulmonary vein superior–inferior diameter (LIPV SID), PV number variation, circumferential pulmonary vein isolation (CPVI) combined with additional ablation, and early recurrence of atrial fibrillation (ERAF). The best cut-off value for LAD was 35.5 mm. Conclusions During a 3-year follow-up, about 70% of the patients with PAF maintained SR. LRAF after a single procedure was associated with the LAD, LIPV SID, PV number variation, CPVI combined with additional ablation, and ERAF.

Transcatheter left atrial appendage occlusion (LAAO) is non-inferior to vitamin K antagonists (VKAs) in preventing thromboembolic events in atrial fibrillation (AF). Non-vitamin K antagonists (NOACs) have an improved safety profile over VKAs, however, evidence regarding their effect on cardiovascular and neurological outcomes relative to LAAO is limited. Up-to-date randomized trials or propensity-score-matched data comparing LAAO vs. NOACs in high-risk patients with AF were pooled in our study. A total of 2849 AF patients (LAAO: 1368, NOACs: 1481, mean age: 75 ± 7.5 yrs, 63.5% male) were enrolled. The mean CHA2DS2-VASc score was 4.3 ± 1.7, and the mean HAS-BLED score was 3.4 ± 1.2. The baseline characteristics were comparable between the two groups. In the LAAO group, the success rate of device implantation was 98.8%. During a mean follow-up of 2 years, as compared with NOACs, LAAO was associated with a significant reduction of ISTH major bleeding (p = 0.0002). There were no significant differences in terms of ischemic stroke (p = 0.61), ischemic stroke/thromboembolism (p = 0.63), ISTH major and clinically relevant minor bleeding (p = 0.73), cardiovascular death (p = 0.63), and all-cause mortality (p = 0.71). There was a trend toward reduction of combined major cardiovascular and neurological endpoints in the LAAO group (OR: 0.84, 95% CI: 0.64–1.11, p = 0.12). In conclusion, for high-risk AF patients, LAAO is associated with a significant reduction of ISTH major bleeding without increased ischemic events, as compared to “contemporary NOACs”. The present data show the superior role of LAAO over NOACs among high-risk AF patients in terms of reduction of major bleeding, however, more randomized controlled trials are warranted.

Background Recurrence rate after radiofrequency catheter ablation (RFCA) remains high, and further investigation on predictors of recurrence is needed. Objects To identify risk factors of atrial fibrillation (AF) recurrence in patients undergoing RFCA. Methods We retrospectively studied 257 patients with AF who underwent RFCA preceded by transthoracic echocardiographic and pulmonary vein CT examination from 2016 to 2019. Electrocardiogram examination was performed at baseline, 1, 3, 6 months, and 1 year after RFCA. We divided patients into two groups based on AF recurrence including recurrence group (n = 79) and nonrecurrence group (n = 178). The crude and independent association between clinical variables and AF recurrence was evaluated with logistic regression analysis. Specificity and positive predictive value of relevant factors for AF recurrence were performed by ROC curve. Results Of these AF patients, 174 (68%) was paroxysmal AF and 83 (32%) was persistent AF. The multivariate logistic regression demonstrated that AF duration (OR = 1.008, 95% CI 1.002-1.013, p = .008), pulmonary arterial hypertension (PAH; OR = 2.313, 95% CI 1.031-5.192, p = .042), and low-density lipoprotein cholesterol (LDL-C; OR = 1.646, 95% CI 1.129-2.398, p = .010) were independently correlated with recurrence of AF. For predicting AF recurrence, the specificity and sensitivity of AF duration were 30.1% and 87.3%, and for LDL-C, the specificity and sensitivity of AF duration were 60.6% and 60.5%, respectively. Conclusions Atrial fibrillation duration, PAH, and LDL-C might be independent risk factors for the recurrence of AF after RFCA.

Background Renin-angiotensin-system inhibitors (RASIs) have been suggested as an upstream therapy for selected AF patients; however, the evidence in surgical setting is limited. Objective We aimed to evaluate the role of preoperative RASIs in prevention of postoperative atrial fibrillation (POAF) and adverse events for patients undergoing cardiac surgery. Methods In this collaborative pooled-analysis, both randomized and nonrandomized controlled trials comparing preoperative RASIs with no preoperative RASIs treatment on the incidence of POAF were identified. Sensitivity and subgroup analyses of RCTs were performed to test the stability of the overall-effect, and meta-regression to explore the potential risk of bias. The primary outcome was POAF, and the secondary outcomes includes rate of stroke, mortality and duration of hospitalization. Results Eleven trials involving 27885 patients (male 74%, median age 65yrs) were included. As compared to the control group, preoperative RASIs did not significantly reduce the risk of POAF (OR: 1.04, 95% CI: 0.91–1.19), stroke (OR: 0.86, 95% CI: 0.62–1.19), death (OR: 1.07, 95% CI: 0.85–1.35), composite adverse cardiac events (OR: 1.04, 95% CI: 0.91–1.18), and hospital stay (WMD: −0.04, 95% CI: −1.05 to 0.98). Pooled-analysis of randomized trials showed consistent results. The primary overall-effect was maintained in sensitivity and subgroup analyses. Meta-regression showed that male-gender was a significant risk-factor of POAF and use of Beta-blockers was associated with a significantly reduced risk in developing POAF. Conclusion and relevance This study demonstrates that preoperative RASIs do not offer additional benefit in reducing the risk of postoperative AF, stroke, death and hospitalization in the setting of cardiac surgery. The results provide no support for use of RASIs for the prevention of POAF and adverse events in patients undergoing cardiac surgery.

Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery, resulting in an increased risk of morbidity and longer hospital stay. Pharmacologic prophylaxis has been recommended to improve the outcome in patients at high risk of developing POAF after cardiac surgery. Several studies have applied the CHAWe systematically searched the Medline, Embase, Cochrane library, and other data sources with key terms "CHASeven hundred twenty-one studies were identified, of which 12 studies with 18,086 patients were finally included in our analysis. The CHAThe CHA

Background: The present study was to evaluate the value of CHADS2 and CHA2DS2VASC scores on predicting left atrial (LA) or left atrial appendage (LAA) thrombus in atrial fibrillation (AF) patients prior to ablation. Methods and results: A total of 397 patients with nonvalvular AF were analyzed to determine the relationship between CHADS2 and CHA2DS2VASC scores and LA/LAA thrombus identified on transesophageal echocardiography prior to ablation. LA/LAA thrombus was present in 38 patients (9.6%). There was a strong association between CHADS2 score or CHA2DS2VASC score and LA/LAA thrombus. No thrombus was identified in patients with CHA2DS2VASC score of 0 regardless of anticoagulation status. However, LA/LAA thrombus was detected in 2.9% patients with CHADS2 score of 0 without adequate anticoagulation, while no thrombus was present in the patients with CHADS2 score of 0 with adequate anticoagulation. Univariate analysis showed that heart failure (LVEF50%), LA ≥ 40 mm, diabetes mellitus, previous stroke or TIA, CAD, hypertension, inadequate coumadin therapy, CHADS2 score of ≥ 2 and CHA2DS2VASC score of ≥ 2 were significantly associated with LA/LAA thrombus. Multivariable Cox regression analysis demonstrated that CHA2DS2VASC score of ≥ 2 (p=0.02) and previous stroke or TIA (p=0.04) were independently associated with LA/LAA thrombus regardless of anticoagulation status. ROC curve analysis showed that CHADS2 score and CHA2DS2VASC score could be similarly used to predict the presence of LA thrombus. Conclusion: Both CHA2DS2VASC and CHADS2 scores were associated with LA/LAA thrombus in non-valvular AF patients. Although CHA2DS2VASC score and CHADS2 score had similar value to predict LA/LAA thrombus, CHA2DS2VASc score was better to identify low-risk patients for LA/LAA thrombus than CHADS2 score without anticoagulation. It seemed safe to perform AF ablation or cardio version in AF patients with a CHA2DS2VASC of 0 without TEE or anticoagulation therapy.

Importance Postoperative atrial fibrillation (POAF) is a well-known complication after cardiac surgery. Renin-angiotensin system inhibitors (RASIs) have been suggested as an upstream therapy for selected patients with AF; however, evidence in the surgical setting is limited. Objective To evaluate the role of preoperative RASIs in prevention of POAF and adverse events for patients undergoing cardiac surgery. Data Sources The PubMed database and the Cochrane Library from inception until December 31, 2018, were searched by using the keywordsrenin-angiotensin system inhibitorsORangiotensin-converting enzyme inhibitorsORangiotensin receptor blockerORaldosterone antagonistANDcardiac surgery. ClinicalTrials.gov was searched from inception until December 31, 2018, by using the keywordspostoperative atrial fibrillation. Study Selection Randomized clinical trials (RCTs) and observational studies comparing the association between preoperative RASI treatment vs no preoperative RASI treatment (control group) and the incidence of POAF were identified. Eleven unique studies met the selection criteria. Data Extraction and Synthesis Pooled analysis was performed using a random-effects model. Sensitivity and subgroup analyses of RCTs were performed to test the stability of the overall effect. Metaregression was conducted to explore potential risk of bias. Main Outcomes and Measures The primary outcome was POAF, and the secondary outcomes included rates of stroke and mortality and duration of hospitalization. Results Eleven unique studies involving 27 885 unique patients (74.4% male; median age, 65 years [range, 58.5-74.5 years]) were included. Compared with the control group, the RASI group did not have a significantly reduced risk of POAF (odds ratio [OR], 1.04; 95% CI, 0.91-1.19;P = .55;z = 0.60), stroke (OR, 0.86; 95% CI, 0.62-1.19;P = .37;z = 0.90; without significant heterogeneity,P = .11), death (OR, 1.07; 95% CI, 0.85-1.35;P = .56;z = 0.59; without significant heterogeneity,P = .12), composite adverse cardiac events (OR, 1.04; 95% CI, 0.91-1.18;P = .58;z = 0.56), or a reduced hospital stay (weighted mean difference, −0.04; 95% CI, −1.05 to 0.98;P = .94;z = 0.07) using a random-effects model. Pooled analysis focusing on RCTs showed consistent results. The primary overall effect was maintained in sensitivity and subgroup analyses. Metaregression showed that male sex was significantly associated with POAF (τ2 = 0.0065;z = 3.47;Q = 12.047;P Conclusions and Relevance The findings from this study suggest that preoperative RASI treatment does not offer additional benefit in reducing the risk of POAF, stroke, death, and hospitalization in the setting of cardiac surgery. The results provide no support for conventional use of RASIs for the possible prevention of POAF and adverse events in patients undergoing cardiac surgery; further randomized data, particularly among those patients with heart failure, are needed.

It is controversial whether angiotensin II receptor blockers provide better protection than calcium antagonists against atrial fibrillation (AF) recurrence in hypertensive patients. This study was designed to compare the effect of nifedipine- and telmisartan-based antihypertensive treatments for preventing AF recurrence in hypertensive patients with paroxysmal AF. A total of 149 hypertensive patients with paroxysmal AF were randomized to nifedipine- or telmisartan-based antihypertensive treatment groups. The target blood pressure (BP) was P =0.742), and Kaplan–Meier analysis showed no significant difference in the freedom from AF recurrence (log-rank test; P =0.48). However, the rate of developing persistent AF in telmisartan group was lower than that in nifedipine group (5.4% versus 16.0%; P =0.035). Patients in telmisartan group had lower values of left atrial diameter, left atrial volume index, and left ventricular mass index at the end of follow-up. The effects of telmisartan in preventing AF recurrences in hypertensive patients with paroxysmal AF after intensive lowering BP is similar to that of nifedipine, but telmisartan has more potent effects on preventing progression to persistent AF.

To predict the recurrence of atrial fibrillation is important for selecting patients who will be undergoing catheter ablation, several studies respectively evaluated the risk factor of the recurrence of atrial fibrillation post-ablation.To investigate the factors predicting the recurrence of atrial fibrillation (AF) after catheter ablation.186 patients (55.12 ± 12.06 years, 123 male) including 161 paroxysmal AF and 25 non-paroxysmal AF who underwent catheter ablation were studied. Clinical datum before and during ablation were recorded, and systematic follow-up was conducted after ablation. Univariate and multivariate analyses were carried out to determine the factors predicting late recurrence of AF (LRAF) which means AF recurrence after 3 months.There were 47(25.27%) patients who experienced LRAF. Multivariate Logistic regression analysis was carried out to the parameters that P0.10 in the univariate analysis, which includes overweight/obesity, metabolic syndrome (MetS), AF categories, duration of AF history, left atrial diameter (LAD), diabetes mellitus, ablation strategies, procedural failure and early recurrence of AF after ablation (ERAF). Ultimately, the results demonstrated that overweight/obesity (OR=4.71, 95% CI 1.71-12.98, P=0.003), MetS (OR=4.41, 95% CI 1.56-12.46, P=0.005), procedural failure (OR=58.34, 95% CI 6.83-498.34, P0.001), and ERAF (OR=3.18, 95% CI 1.07-9.44, P=0.037) were independent predictors of AF recurrence after ablation.Overweight/obesity, metabolic syndrome, procedural failure and ERAF are independent predictors of late recurrence of atrial fibrillation in this group of patients.

BACKGROUND:The efficacy of short-term antiarrhythmic drugs (AADs) use compared with no-AADs prescription after catheter ablation of atrial fibrillation (AF) in preventing atrial arrhythmia recurrence is uncertain. METHODS:We searched PubMed, Embase, and the Cochrane Library through December 2015 to identify randomized controlled trials (RCTs) which evaluated the efficacy of short-term AADs use compared with no-AADs prescription after AF ablation in preventing atrial arrhythmia recurrence. The primary outcome was labeled as early atrial arrhythmia recurrence within 3 months after ablation. Secondary outcome was defined as late recurrence after 3 months of ablation. Random-effects model or fixed-effects model was used to estimate relative risks (RRs) with 95% confidence intervals (CIs). RESULTS:Six RCTs with 2,667 patients were included into this meta-analysis. Compared with no-AADs administration after AF ablation, short-term AADs use was associated with significant reduction of early atrial arrhythmia recurrence (RR, 0.68; 95% CI, 0.52-0.87; p = 0.003). Trial sequential analysis (TSA) showed that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit, establishing sufficient and conclusive evidence. However, compared with no-AADs prescription, short-term AADs use after AF ablation didn't significantly reduce the risk of late atrial arrhythmia recurrence (RR, 0.92; 95% CI, 0.83-1.03; p = 0.15). TSA supported this result; meanwhile the estimated required information size (1,486 patients) was also met. CONCLUSION:Short-term use of AADs after AF ablation can significantly decrease the risk of early atrial arrhythmia recurrence but not lead to corresponding reduction in risk of late atrial arrhythmia recurrence.

The purpose of this study was to compare the efficacy of focused ultrasound circumferential pulmonary vein ablation (CPVa) and BOX ablation (BOXa) in an acute atrial fibrillation (AF) model. Twenty mongrel dogs were divided into either CPVa or BOXa groups. CPV or BOX focused ultrasonic ablation was conducted in each group after successful establishment of the AF model. Before-and-after ablation left atrial effective refractory period (LAERP), AF inducibility, and induced AF lasting time were measured in both groups. The LAERP after AF model establishment was significantly shorter than that before establishment (102 ± 10 vs. 140 ± 10 ms, p

The purpose of this study is to evaluate the relationship between plasma high-sensitivity C-reactive protein (hs-CRP), atrial natriuretic peptides (ANP), N-terminal-pro-brain natriuretic peptide (NT-proBNP) levels, and the risk and recurrence of atrial fibrillation (AF) after pulmonary vein isolation (PVI) in patients with paroxysmal atrial fibrillation (PAF).Plasma ANP, NT-proBNP, and hs-CRP levels were measured before and 3 months after PVI in 33 patients with PAF and 30 control participants.(1) NT-proBNP levels at baseline were significantly elevated in subjects with PAF compared with control subjects (296.8 ± 272.1 vs. 80.8 ± 69.1 pg/ml), but ANP and hs-CRP levels were normal; NT-proBNP levels normalized 3 months after PVI, but ANP and hs-CRP levels did not change significantly; NT-proBNP levels at baseline in the recurrent group were markedly higher than those in the nonrecurrent AF group (572.7 ± 234.2 vs. 176.8 ± 188.7 pg/ml). (2) Cox stepwise multivariate analysis demonstrated that only elevated NT-proBNP level at baseline was an independent predictor of AF recurrence (p 0.001) after PVI among 13 variables, such as echocardiographic parameters, plasma ANP, NT-proBNP, and hs-CRP levels. A cutoff value of NT-proBNP ≥ 423.2 pg/ml was a significant risk factor for AF recurrence (p = 0.002).Elevated NT-proBNP level at baseline, but not ANP and hs-CRP, is a sensitive biomarker for early predicting AF recurrence in patients with PAF.

The effect of different treatment strategies of atrial fibrillation on left atrial (LA) size has not been compared in lone paroxysmal atrial fibrillation. The objective of the present study was to evaluate the evolution of LA size over time in patients who underwent different treatment interventions. Two hundred forty patients with lone paroxysmal atrial fibrillation were assigned to four groups. The circumferential pulmonary vein ablation (CPVA) group (n = 60) was treated with CPVA, segmental pulmonary vein isolation (SPVI) group (n = 60) with SPVI, AMIO group (n = 60) with amiodarone alone, and AMIO + LO group (n = 60) with amiodarone plus losartan. LA diameter was measured with transthoracic echocardiogram at baseline, 3, 6, 9, and 12 months after the interventions. In the CPVA group, LA size at third, sixth, ninth, and 12th month had a significant decrease than that at baseline and in the other three groups. LA size in patients with atrial fibrillation recurrence in the four groups was significant higher than that in patients with no atrial fibrillation recurrence (P = 0.002–0.001). The results suggested that a shortened LA size is not consistent with improved sinus rhythm maintenance. Although maintenance of sinus rhythm is not the only factor in determining shrinking or enlargement of the left atrium, inhibiting or eliminating activity of the pulmonary vein is very important for paroxysmal atrial fibrillation. Atrial fibrillation recurrence is a main factor contributing to enlargement of the LA.

Background Previous studies have shown that contrast-enhanced multidetector computed tomography (CE-MDCT) could identify ventricular fibrosis after myocardial infarction. However, whether CE-MDCT can characterize atrial low-voltage regions remains unknown. Objective The purpose of this study was to examine the association of CE-MDCT image attenuation with left atrial (LA) low bipolar voltage regions in patients undergoing repeat ablation for atrial fibrillation recurrence. Methods We enrolled 20 patients undergoing repeat ablation for atrial fibrillation recurrence. All patients underwent preprocedural 3-dimensional CE-MDCT of the LA, followed by voltage mapping (>100 points) of the LA during the ablation procedure. Epicardial and endocardial contours were manually drawn around LA myocardium on multiplanar CE-MDCT axial images. Segmented 3-dimensional images of the LA myocardium were reconstructed. Electroanatomic map points were retrospectively registered to the corresponding CE-MDCT images. Results A total of 2028 electroanatomic map points obtained in sinus rhythm from the LA endocardium were registered to the segmented LA wall CE-MDCT images. In a linear mixed model, each unit increase in the local image attenuation ratio was associated with 25.2% increase in log bipolar voltage (P = .046) after adjusting for age, sex, body mass index, and LA volume, as well as clustering of data by patient and LA regions. Conclusion We demonstrate that the image attenuation ratio derived from CE-MDCT is associated with LA bipolar voltage. The potential ability to image fibrosis via CE-MDCT may provide a useful alternative in patients with contraindications to magnetic resonance imaging.

The purpose of this trial was to compare the long-term efficacy of low-dose amiodarone with losartan and perindopril (both combined with low-dose amiodarone) for the prevention of atrial fibrillation (AF) recurrence in patients with lone paroxysmal AF.One-hundred and seventy-seven patients with lone paroxysmal AF were randomly assigned to three treatment groups: group 1 received low-dose amiodarone alone, group 2 received low-dose amiodarone plus losartan, and group 3 received low-dose amiodarone plus perindopril. Left atrial diameter was measured with transthoracic echocardiogram at baseline and 6, 12, 18, and 24 months after randomization. The primary endpoint was the incidence of AF documented by 12-lead ECG or Holter after 14 days and within 24 months after randomization. The primary endpoint was reached in 24 patients (41%) in group 1, 11 (19%) in group 2, and 14 (24%) in group 3 (P = 0.02). The Kaplan-Meier survival analysis demonstrated a significant reduction in AF recurrence in group 2 (P = 0.006, log-rank test) as well as in group 3 (P = 0.04, log-rank test) when compared with group 1. No difference in the AF recurrence-free survival was found between group 2 and group 3. After 24 months follow-up, the left atrial diameter in group 2 and group 3 was significantly smaller than that in group 1 (36 +/- 2.3 and 35 +/- 2.4 vs. 38 +/- 2.4 mm, P0.001 for both comparisons).The results of this study suggest that the combination of perindopril or losartan with low-dose amiodarone is more effective than low-dose amiodarone alone for the prevention of AF recurrence in patients with lone paroxysmal AF. Adding losartan or perindopril to amiodarone can inhibit left atrial enlargement in this group of patients.

The efficacy of short-term antiarrhythmic drugs (AADs) use compared with no-AADs prescription after catheter ablation of atrial fibrillation (AF) in preventing atrial arrhythmia recurrence is uncertain. We searched PubMed, Embase, and the Cochrane Library through December 2015 to identify

Background: The study was to evaluate the value of CHADS2 and CHADS2VASC scores on predicting left atrial (LA) thrombus in the patients with atrial fibrillation (AF). Methods and Results: All the non-valvular AF patients undergoing AF ablation from June 2010 to June 2012 were included and divided into two groups: patients without anticoagulation and with Coumadin anticoagulation for at least 4 weeks. The relationship between CHADS2 and CHADS2VASC scores and LA thrombus as identified on transesophageal echocardiography (TEE) was analyzed prior to ablation. A total of 397 patients underwent pre-ablation TEE: 212 patients without anticoagulation, and 185 with anticoagulation. There were no differences in the CHADS2 and CHADS2VASC scores in the two groups. LA thrombus was present in 15.6% and 5.9% for the patients without anticoagulation and for those with anticoagulation, respectively (p = 0.002). There was a strong association between CHADS2 and LA thrombus, and between CHADS2VASC and LA thrombus in the two groups. No thrombus was identified in patients with CHADS2VASC score of 0 in both groups. However, thrombus was detected in 3.5% of patients with CHADS2 score of 0 in the group without anticoagulation, while no thrombus was present in the ones with anticoagulation. CHADS2VASC score of ≥1 (r=2.03, p = 0.04) was the only factor independently associated with LA thrombus in patients without anticoagulation, while both CHADS2VASC score of ≥2 (r=2.61, p=0.02) and CHADS2 score of ≥2 (r=2.73, p=0.01) were independently associated with LA thrombus. Further analyses showed that CHADS2VASC score was a better predictor for LA thrombus than CHADS2 score in patients without anticoagulation. However, there was no difference between the two scoring systems in predicting LA thrombus in patients with anticoagulation. Conclusions: LA thrombus was associated with CHADS2VASC and CHADS2 scores in non-valvular AF patients without anticoagulation. CHADS2VASC score was a better predictor than CHADS2 score for LA thrombus in patients without anticoagulation. The data suggested that it might be unnecessary to undergo a TEE evaluation for LA thrombus in low risk patients identified by CHADS2VASC score regardless anticoagulation therapy prior to cardioversion or ablation.

The purpose of this study was to investigate whether atrial overexpression of angiotensin-converting enzyme 2 (ACE2) by homogeneous transmural atrial gene transfer can reverse atrial remodeling and its mechanisms in a canine atrial-pacing model. Twenty-eight mongrel dogs were randomly divided into four groups: Sham-operated, AF-control, gene therapy with adenovirus-enhanced green fluorescent protein (Ad-EGFP) and gene therapy with Ad-ACE2 (Ad-ACE2) (n = 7 per subgroup). AF was induced in all dogs except the Sham-operated group by rapid atrial pacing at 450 beats/min for 2 weeks. Ad-EGFP and Ad-ACE2 group then received epicardial gene painting. Three weeks after gene transfer, all animals except the Sham group underwent rapid atrial pacing for another 3 weeks and then invasive electrophysiological, histological and molecular studies. The Ad-ACE2 group showed an increased ACE2 and Angiotensin-(1–7) expression, and decreased Angiotensin II expression in comparison with Ad-EGFP and AF-control group. ACE2 overexpression attenuated rapid atrial pacing-induced increase in activated extracellular signal-regulated kinases and mitogen-activated protein kinases (MAPKs) levels, and decrease in MAPK phosphatase 1(MKP-1) level, resulting in attenuation of atrial fibrosis collagen protein markers and transforming growth factor-β1. Additionally, ACE2 overexpression also modulated the tachypacing-induced up-regulation of connexin 40, down-regulation of connexin 43 and Kv4.2, and significantly decreased the inducibility and duration of AF. ACE2 overexpression could shift the renin–angiotensin system balance towards the protective axis, attenuate cardiac fibrosis remodeling associated with up-regulation of MKP-1 and reduction of MAPKs activities, modulate tachypacing-induced ion channels and connexin remodeling, and subsequently reduce the inducibility and duration of AF. Electronic supplementary material The online version of this article (doi:10.1007/s00395-015-0499-0) contains supplementary material, which is available to authorized users.

antiplatelet therapy after coronary stenting: a randomizedmulticenter trial. Circulation Apr 24 2012;125(16):2015–26. [6] Campo G, Tebaldi M, Vranckx P, et al. Short vs. long term duration of dual antiplatelet therapy in patients treated for in-stent restenosis. A PRODIGY trial substudy. J Am Coll Cardiol 2014;63(6):506–12. [7] Valgimigli M, Tebaldi M, Borghesi M, et al. Two-year outcomes after firstor secondgeneration drug-eluting or bare-metal stent implantation in all-comer patients undergoing percutaneous coronary intervention: a pre-specified analysis from the PRODIGY study. JACC Cardiovasc Interv 2014;7(1):20–8.

Background Although amiodarone plus angiotensin II receptor blockers (ARBs) and catheter ablation may improve sinus rhythm maintenance of paroxysmal atrial fibrillation (AF), their clinical efficacies have not been compared. This prospective cohort study was designed to compare clinical efficacy of catheter ablation and amiodarone plus losartan on sinus rhythm maintenance in patients with paroxysmal AF. Materials and methods A total of 240 patients with paroxysmal AF were assigned to four groups. CPVA group (n = 60) was treated with circumferential pulmonary vein ablation (CPVA), SPVI group (n = 60) with segmental pulmonary vein isolation, AMIO group (n = 60) with amiodarone and AMIO + LO group (n = 60) with amiodarone plus losartan. The endpoint was documented recurrence of AF > 30 s by Holter or conventional 12-lead ECG in the 1-year follow-up period. Results During 12 months of follow-up, the primary end point was reached in 28 patients in CPVA group, 14 patients in SPVI group, 25 patients in AMIO group and 13 patients in AMIO + LO group, respectively. The sinus rhythm in SPVI and AMIO + LO group were significant higher than that in CPVA and AMIO group (P