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Aims: Incorporating patient-reported outcomes (PROs) into routine care of atrial fibrillation (AF) enables direct integration of symptoms, function, and health-related quality of life (HRQoL) into practice. We report our initial experience with a system-wide PRO initiative among AF patients.Methods and Results: All patients with AF in our practice undergo PRO assessment with the Toronto AF Severity Scale (AFSS), and generic PROs, prior to electrophysiology clinic visits. We describe the implementation, feasibility, and results of clinic-based, electronic AF PRO collection, and compare AF-specific and generic HRQoL assessments. From October 2016 to February 2019, 1586 unique AF patients initiated 2379 PRO assessments, 2145 of which had all PRO measures completed (90%). The median completion time for all PRO measures per visit was 7.3 min (1st, 3rd quartiles: 6, 10). Overall, 38% of patients were female (n = 589), mean age was 68 (SD 12) years, and mean CHA2DS2-VASc score was 3.8 (SD 2.0). The mean AFSS symptom score was 8.6 (SD 6.6, 1st, 3rd quartiles: 3, 13), and the full range of values was observed (0, 35). Generic PROs of physical function, general health, and depression were impacted at the most severe quartiles of AF symptom score (P < 0.0001 for each vs. AFSS quartile).Conclusion: Routine clinic-based, PRO collection for AF is feasible in clinical practice and patient time investment was acceptable. Disease-specific AF PROs add value to generic HRQoL instruments. Further research into the relationship between PROs, heart rhythm, and AF burden, as well as PRO-guided management, is necessary to optimize PRO utilization. [ABSTRACT FROM AUTHOR]

Electroanatomic Map Overestimates the Ablated Area Background Three-dimensional electroanatomic mapping (EAM) is routinely used to mark ablated areas during radiofrequency ablation. We hypothesized that, in atrial fibrillation (AF) ablation, EAM overestimates scar formation in the left atrium (LA) when compared to the scar seen on late-gadolinium enhancement magnetic resonance imaging (LGE-MRI). Methods and Results Of the 235 patients who underwent initial ablation for AF at our institution between August 2011 and December 2012, we retrospectively identified 70 patients who had preprocedural magnetic resonance angiography merged with LA anatomy in EAM software and had a 3-month postablation LGE-MRI for assessment of scar. Ablated area was marked intraprocedurally using EAM software and quantified retrospectively. Scarred area was quantified in 3-month postablation LGE-MRI. The mean ablated area in EAM was 30.5 ± 7.5% of the LA endocardial surface and the mean scarred area in LGE-MRI was 13.9 ± 5.9% (P < 0.001). This significant difference in the ablated area marked in the EAM and scar area in the LGE-MRI was present for each of the 3 independent operators. Complete pulmonary vein (PV) encirclement representing electrical isolation was observed in 87.8% of the PVs in EAM as compared to only 37.4% in LGE-MRI (P < 0.001). Conclusions In AF ablation, EAM significantly overestimates the resultant scar as assessed with a follow-up LGE-MRI. [ABSTRACT FROM AUTHOR]

Background Magnetic resonance imaging (MRI) can visualize locations of both the ablation scar on the left atrium (LA) after atrial fibrillation (AF) ablation and epicardial fat pads (FPs) containing ganglionated plexi (GP). Methods We investigated 60 patients who underwent pulmonary vein antrum (PVA) isolation along with LA posterior wall and septal debulking for AF. FPs around the LA surface in well-known GP areas (which were considered as the substitution of GP areas around the LA) were segmented from the dark-blood MRI. Then the FP and the ablation scar image visualized by late gadolinium enhancement (LGE)-MRI on the LA were merged together. Overlapping areas of FP and the ablation scar image were considered as the ablated FP areas containing GP. Patients underwent 24-hour Holter monitoring after ablation for the analysis of heart rate variability. Results Ablated FP area was significantly wider in patients without AF recurrence than those in patients with recurrence (5.6 ± 3.1 cm2 vs 4.2 ± 2.7 cm2, P = 0.03). The mean values of both percentage of differences greater than 50 ms in the RR intervals (pRR > 50) and standard deviation of RR intervals over the entire analyzed period (SDNN), which were obtained from 24-hour Holter monitoring 1-day post-AF ablation, were significantly lower in patients without recurrence than those in patients with recurrence (5.8 ± 6.0% vs 14.0 ± 10.1%; P = 0.0005, 78.7 ± 32.4 ms vs 109.2 ± 43.5 ms; P = 0.005). There was a significant negative correlation between SDNN and the percentage of ablated FP area (Y = −1.3168X + 118.96, R2 = 0.1576, P = 0.003). Conclusion Extensively ablating LA covering GP areas along with PVA isolation enhanced the denervation of autonomic nerve system and seemed to improve procedural outcome in patients with AF. [ABSTRACT FROM AUTHOR]

Background: Myocardial perfusion cardiovascular magnetic resonance (CMR) is a well-established method for detection of ischemic heart disease. However, ECG gating problems can result in image degradation and non-diagnostic scans, particularly in patients with arrhythmias. Methods: A turboFLASH saturation recovery pulse sequence was used without any ECG triggering. One saturation pulse followed by 4-5 slices of undersampled radial k-space images was acquired rapidly, on the order of 40-50 msec per image. The acquisition of the set of 4-5 slices was continuously repeated approximately 4 times per second. An iterative constrained reconstruction method was used to reconstruct the ungated images. The ungated perfusion images were post-processed into three different sets of images (ungated, self-gated to near systole, and self-gated to near diastole). To test the ungated approach and compare the different processing methods, 8 patients scheduled for coronary angiography underwent stress and rest perfusion imaging with the ungated acquisition. Six patients had a history of atrial fibrillation (AF). Three blinded readers assessed image quality and presence/absence of disease. Results: All 8 subjects successfully completed the perfusion CMR protocol and 7/8 underwent coronary angiography. Three patients were in atrial fibrillation during CMR. Overall, the CMR images were of high quality as assessed by the three readers. There was little difference in image quality between patients in AF compared to those in sinus rhythm (3.6±0.7 vs. 3.3±0.5). Stress/rest perfusion imaging showed normal perfusion in 4 patients, fixed perfusion defects in 2 patients, and reversible perfusion defects in 2 patients, corresponding with angiographic results. Pooled results from the independent readers gave a sensitivity of 0.92 (CI 0.65-0.99) and specificity of 0.92 (CI 0.65-0.99) for the detection of coronary artery disease using ungated perfusion imaging. The same sensitivity, and a specificity of 1 (CI 0.76-1), was achieved when the images were self-gated after acquisition into near systole or near diastole. Conclusions: Ungated radial dynamic perfusion CMR can give high quality imaging in patients in sinus rhythm and during atrial fibrillation. In this small cohort, high diagnostic accuracy was possible with this rapid perfusion imaging sequence. An ungated approach simplifies the acquisition and could expand the role of perfusion CMR to include patients with arrhythmia and those with gating problems. [ABSTRACT FROM AUTHOR]

Aims: Incorporating patient-reported outcomes (PROs) into routine care of atrial fibrillation (AF) enables direct integration of symptoms, function, and health-related quality of life (HRQoL) into practice. We report our initial experience with a system-wide PRO initiative among AF patients., Methods and Results: All patients with AF in our practice undergo PRO assessment with the Toronto AF Severity Scale (AFSS), and generic PROs, prior to electrophysiology clinic visits. We describe the implementation, feasibility, and results of clinic-based, electronic AF PRO collection, and compare AF-specific and generic HRQoL assessments. From October 2016 to February 2019, 1586 unique AF patients initiated 2379 PRO assessments, 2145 of which had all PRO measures completed (90%). The median completion time for all PRO measures per visit was 7.3 min (1st, 3rd quartiles: 6, 10). Overall, 38% of patients were female (n = 589), mean age was 68 (SD 12) years, and mean CHA2DS2-VASc score was 3.8 (SD 2.0). The mean AFSS symptom score was 8.6 (SD 6.6, 1st, 3rd quartiles: 3, 13), and the full range of values was observed (0, 35). Generic PROs of physical function, general health, and depression were impacted at the most severe quartiles of AF symptom score (P < 0.0001 for each vs. AFSS quartile)., Conclusion: Routine clinic-based, PRO collection for AF is feasible in clinical practice and patient time investment was acceptable. Disease-specific AF PROs add value to generic HRQoL instruments. Further research into the relationship between PROs, heart rhythm, and AF burden, as well as PRO-guided management, is necessary to optimize PRO utilization., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Objectives: The aim of this study was to define the population-based familial clustering of atrial fibrillation (AF) that is associated with fibrosis and describe evidence for a heritable predisposition., Background: Although a heritable contribution to AF is well-established and the association of fibrosis with AF is well-recognized, no studies have analyzed the genetic contribution to AF co-occurring with fibrosis., Methods: AF patients with magnetic resonance imaging-confirmed fibrosis were identified in a population-based health sciences center database linked to a Utah genealogy. Familial clustering of AF/fibrosis was defined by analysis of pairwise case relatedness, estimation of relative risk of AF/fibrosis in relatives, and identification of high-risk AF/fibrosis pedigrees., Results: The 694 individuals identified with AF/fibrosis who had at least 3 generations of genealogy data were found to have significantly elevated pairwise relatedness (p < 0.001), even when first- and second-degree relationships were ignored (p < 0.001). Significantly elevated risks for AF/fibrosis among first- (relative risk [RR]: 4.65), second- (RR: 3.14), and third-degree (RR: 2.70) relatives of individuals with AF/fibrosis were observed. We identified 157 extended Utah pedigrees with a significant excess of AF/fibrosis among descendants., Conclusions: There is a strong heritable contribution to predisposition to AF co-occurring with fibrosis. We suggest that this study provides a unique foundation for a search for predisposition genes, specifically for AF co-occurring with fibrosis., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aim: Age and female sex are associated with a higher risk of stroke in atrial fibrillation (AF). We sought to determine whether advancing age and female sex are associated with higher atrial fibrosis., Methods and Results: We conducted an observational cohort study of patients with AF enrolled in the University of Utah AF Database and a non-AF control group who underwent late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) for atrial fibrosis quantification. Participants with contra-indications for contrast MRI scanning were excluded. Nine hundred and eight consecutive men and women with AF and 15 non-AF controls were included in this study. Left atrial fibrosis increased with age in both men and women with AF. Women with AF (n = 316) were older than men (n = 592): mean age 68.7±11.6 vs. 64.9±11.7 years; P < 0.01, and had higher left atrial fibrosis compared with men 17.5 ± 10.1% vs. 15.3 ± 8.9%; P < 0.001. Women also had a higher prevalence of prior stroke compared with men (15.8% vs. 6.5%; P < 0.001). Age and sex relationships with atrial fibrosis remained significant in multivariate analysis. Compared with the non-AF control group, patients with AF had significantly higher atrial fibrosis: 16.0 ± 9.4 vs. 5.5 ± 5.8%; P < 0.001., Conclusions: Advancing age and female sex are associated with a higher burden of atrial fibrosis in patients with AF. Women with a prior history of stroke also have higher fibrosis compared with both women and men without history of stroke. Advanced fibrosis may explain the female and age association with stroke in AF.

Purpose: Patients routinely undergo ablation for atrial fibrillation (AF) but the recurrence rate remains high. We explored in this study whether poor scar formation as seen on late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) correlates with AF recurrence following ablation., Methods: We retrospectively identified 94 consecutive patients who underwent their initial ablation for AF at our institution and had pre-procedural magnetic resonance angiography (MRA) merged with left atrial (LA) anatomy in an electroanatomic mapping (EAM) system, ablated areas marked intraprocedurally in EAM, 3-month post-ablation LGE-MRI for assessment of scar, and minimum of 3-months of clinical follow-up. Ablated area was quantified retrospectively in EAM and scarred area was quantified in the 3-month post-ablation LGE-MRI., Results: With the mean follow-up of 336 days, 26 out of 94 patients had AF recurrence. Age, hypertension, and heart failure were not associated with AF recurrence, but LA size and difference between EAM ablated area and LGE-MRI scar area was associated with higher AF recurrence. For each percent higher difference between EAM ablated area and LGE-MRI scar area, there was a 7-9% higher AF recurrence (p values 0.001-0.003) depending on the multivariate analysis., Conclusions: In AF ablation, poor scar formation as seen on LGE-MRI was associated with AF recurrence. Improved mapping and ablation techniques are necessary to achieve the desired LA scar and reduce AF recurrence.

Aims: Pulmonary vein antrum isolation (PVAI) plays a pivotal role in the comprehensive treatment of atrial fibrillation (AF). The need for effective anticoagulation bridging following PVAI is associated with significant vascular complication rates and increased costs. We investigated the safety of PVAI in patients with therapeutic international normalized ratios (INR) the day of the procedure., Methods: A case-control analysis was performed on patients who underwent PVAI with therapeutic INR (>2). Patients with normal preprocedure INR served as controls. The incidence of major and minor hematomas, fistulas, vascular injury, and cardiac perforation or tamponade were catalogued. PVAI was performed under fluoroscopic, electro-anatomical, and intracardiac echocardiographic guidance, with an open irrigation ablation technique., Results: A total of 194 patients (mean age 64 +/- 12) were included; 87 patients underwent PVAI with therapeutic INR (cases) and 107 with normal INR (controls). Persistent AF was more prevalent than paroxysmal AF in the therapeutic INR group. The mean INR for cases was 2.8 +/- 0.7 compared to 1.4 +/- 0.3 in the control group (P < 0.01). All procedures were completed without acute complications. Two major adverse events were observed, one in each arm. No significant difference in terms of minor (6.5% vs. 5.7%, P = 0.23) or major (0.93% vs. 1.15%, P = 0.49) vascular events or bleeding was detected between the therapeutic INR and the control group. The combined endpoint of major and minor complications did not differ among groups (9.35% vs. 8.05%, P = 0.19)., Conclusion: Atrial fibrillation ablation in patients with therapeutic INR on the day of a procedure appears to be safe and feasible. Expensive outpatient anti-coagulation bridging may be safely avoided in this type of population.

Background: The incidence of atrial flutter (AFL) post pulmonary vein antrum isolation (PVAI) in patients with atrial fibrillation (AF) is reported to be between 8% and 20%. The need for right or left AFL ablation during the initial PVAI procedure remains controversial. We prospectively compared mapping and ablation versus no ablative treatment of inducible AFL during PVAI., Methods and Results: In 220 patients (167 men, mean age 56+/-15 years) with symptomatic AF presenting for PVAI, burst pacing from the high right atrium and coronary sinus was performed to determine AFL inducibility. A total of 25 patients with sustained (17 patients) or reproducible (eight patients) AFL were included in this study. Patients were randomized to mapping and ablation of AFL using the CARTO 3D mapping system (Biosense Webster, Diamond Bar, CA, USA) versus no further ablation. Typical AFL was induced in 48% of the patients. During a follow-up of 12+/-4 months, recurrences were determined by serial 48-h Holter and event monitors. Recurrence rates, time to recurrence, and AFL cycle length differences between both groups were not statistically significant., Conclusion: These data suggest that inducibility of AFL post PVAI does not predict long-term incidence of AFL. Moreover, this study demonstrates little benefit to mapping and ablation of these arrhythmias during the PVAI procedures.