Search

BACKGROUND: An atrial septal occluder (ASO) represents a major obstacle to the widespread adoption of atrial fibrillation (AF) catheter ablation in patients with prior atrial septal defect (ASD) closure. AIMS: The aim of this study was to describe the “sequential technique” of transseptal puncture (TSP) in AF patients with ASO. METHODS: Sixty-four drug-refractory AF patients with ASO who underwent catheter ablation in our centre from September 2007 to March 2020 were enrolled. RESULTS: Puncture through the native septum was achieved in 29 patients (Group A) and through the device in 35 patients (Group B). The mean diameter of the occluder was significantly larger in Group B than in Group A (31.6±4.6 mm vs 22.8±3.5 mm, p

Background Atrial fibrillation (AF) and stable coronary artery disease (SCAD) frequently coexist. Hypothesis To investigate the prognosis of catheter ablation versus drug therapy in patients with AF and SCAD. Methods In total, 25 512 patients with AF in the Chinese AF Registry between 2011 and 2019 were screened for SCAD. 815 patients with AF and SCAD underwent catheter ablation therapy were matched with patients by drug therapy in a 1:1 ratio. Primary end point was composite of thromboembolism, coronary events, major bleeding, and all‐cause death. The secondary endpoints were each component of the primary endpoint and AF recurrence. Results Over a median follow‐up of 45 ± 23 months, the patients in the catheter ablation group had a higher AF recurrence‐free rate (53.50% vs. 18.41%, p

Perimitral atrial tachycardia (PMAT) is the most frequent type of iatrogenic atrial tachycardia (AT) after atrial fibrillation (AF) ablation. Vein of Marshall ethanol infusion (EIVOM) is a promising technique in mitral isthmus (MI) ablation.A total of 165 patients with PMAT were divided into three groups according to ablation strategies, including RF only group (n = 89), RF-EIVOM group (initial RF ablation with adjunctive EIVOM, n = 28), and EIVOM-RF group (first-step EIVOM with touch-up RF ablation, n = 48). Acute and follow-up procedure outcomes were evaluated.PMAT terminated in 89.9%, 89.3%, and 93.7% of patients in RF only, RF-EIVOM and EIVOM-RF groups, respectively (p = .715), with complete MI block achieved in 80.9%, 89.3%, and 95.8% of patients (EIVOM-RF vs. RF only, p = .012). First-step utilization of EIVOM was associated with a significant shortening of RF ablation time at MI (EIVOM-RF 2.1 ± 1.3 min, RF only 7.9 ± 5.9 min, RF-EIVOM 6.8 ± 5.8 min; p .001) and a decrease in the proportion of patients need ablation within coronary sinus (CS, EIVOM-RF 14.6%, RF only 61.8%, RF-EIVOM 64.3%; p .001). After a mean follow-up of 12.1 ± 6.2 months, AF/AT recurred in 39 (43.8%), 6 (21.4%), and 12 (25.0%) patients in RF only, RF-EIVOM, and EIVOM-RF group (RF-EIVOM vs. RF only, p = .026; EIVOM-RF vs. RF only, p = .022).EIVOM was associated with an enhanced acute MI block rate as well as reduced AF/AT recurrence. First-step utilization of EIVOM promises to significantly simplify the RF ablation process.PMAT is the most common type of iatrogenic AT after AF ablation procedures. EIVOM contributed to a higher acute MI block rate and lower arrhythmia recurrence risk during follow-up. First-step utilization of EIVOM significantly reduced the need for radiofrequency ablation at MI and inside CS with the advantage of creating a homogenous, transmural lesion and eliminating epicardial connections.

Background Left ventricular thrombus (LVT) is a common complication of dilated cardiomyopathy (DCM), causing morbidity and mortality. Methods This study retrospectively analyzed patients with DCM from January 2002 to August 2020 in Beijing Anzhen Hospital. Clinical characteristics were compared between the LVT group and the age and sex 1:4 matched with the LVT absent group. The receiver operator characteristic (ROC) curve was plotted to evaluate the diagnostic value of D-dimer predicting LVT occurrence in DCM. Results A total of 3,134 patients were screened, and LVT was detected in 72 (2.3%) patients on echocardiography. The patients with LVT had higher D-dimer, fibrinogen, and lower systolic blood pressure than those without LVT. The ejection fraction (EF) was lower and left ventricular end-systolic diameter was larger in the LVT group. Severe mitral regurgitation (MR) was more common in the LVT absent groups. The prevalence of atrial fibrillation was lower in the LVT group. The ROC curve analysis yielded an optimal cut-off value of 444 ng/mL DDU (D-dimer units) for D-dimer to predict the presence of LVT. Multivariable binary logistic regression analysis revealed that EF (OR = 0.90, 95% CI = 0.86–0.95), severe MR (OR = 0.19, 95% CI = 0.08–0.48), and D-dimer level (OR = 15.4, 95% CI = 7.58–31.4) were independently associated with LVT formation. Conclusion This study suggested that elevated D-dimer levels (>444 ng/mL DDU) and reduced EF were independently associated with increased risk of LVT formation. Severe MR could decrease the incidence of LVT.

Aims Fascicular ventricle tachycardia (FVT) arising from the proximal aspect of left His-Purkinje system (HPS) has not been specially addressed. Current study was to investigate its clinical, electrocardiographic, and electrophysiological characteristics. Methods and results Eighteen patients who were identified as this rare FVT were consecutively enrolled, and their scalar electrocardiogram and electrophysiological data were collected and analysed. The ventricular tachycardia (VT) morphology was similar to sinus rhythm (SR) in eight patients, left bundle branch block type in one patient, right bundle branch block type in seven patients, and both narrow and wide QRS type in two patients. During VT, right-sided His potential preceded the QRS with His-ventricle (H-V) interval of 36.3 ± 12.4 ms, which was shorter than that during SR (−51.4 ± 8.6 ms) (P = 0.002). The earliest Purkinje potentials (PPs) were recorded within 7 ± 3 mm of left-side His and preceded the QRS by 49.1 ± 14.0 ms. Mapping along the left anterior fascicle and left posterior fascicle revealed an antegrade activation sequence in all with no P1 potentials recorded. In the two patients with two VT morphologies, the earliest PP was documented at the same site, and the activation sequence of HPS remained antegrade. Ablation at the earliest PP successfully eliminated the tachycardia, except one patient who developed complete atrial-ventricular block and two patients who abandoned ablations. After at least 12 months follow-up, 15 patients were free from any recurrences. Conclusions Fascicular ventricle tachycardia arising from the proximal aspect of left HPS was featured by recording slightly shorter H-V interval and absence of P1 potentials. Termination of VT requires ablation at the left-sided His or its adjacent region.

Debates exist in the repeat ablation strategy for patients with recurrence presenting as persistent atrial fibrillation (AF) after initial persistent AF ablation.To compare the outcome between the "2C3L" and "extensive ablation" approach in patients undergoing repeat procedures for recurrent persistent AF.Propensity-score matching was performed in 196 patients with AF recurrence undergoing repeat ablation, and 79 patients treated with "2C3L" strategy were matched to 79 patients treated with "extensive ablation" strategy. The "2C3L" approach included pulmonary vein isolation, mitral isthmus, left atrial roof, and cavotricuspid isthmus ablation, while the "extensive ablation" strategy included extensive ablation of a variety of other targets aiming to terminate the AF. The primary outcome was freedom from any atrial tachyarrhythmia after 24-h ambulatory monitoring follow-up for 12 months.No statistically significant difference was found between the primary outcome between the "2C3L" and the "extensive ablation" group [70.9% vs. 69.6%, p = .862; 95% confidence interval (CI) -12.8 to 15.3], although the "extensive ablation" group had a significantly high proportion of AF termination (19.0% for "2C3L" vs. 41.8% for "extensive ablation" group, p = .002; 95% CI 8.5-35.9). And AF termination was not related to the primary outcome in multifactorial regression. At 40 ± 22 months after the repeat procedure, the primary outcome was also comparable (57.0 % for "2C3L" vs. 48.1% for "extensive ablation" group, p = .265; 95% CI -6.6 to 23.7).The outcome between the "2C3L" and "extensive ablation" approaches was comparable in patients undergoing repeat procedures for recurrent persistent AF.

Atrial fibrillation (AF) and stable coronary artery disease (SCAD) frequently coexist. This study aimed to assess the long-term outcome of catheter ablation in patients with paroxysmal AF and SCAD.In total, 12,104 patients with paroxysmal AF underwent catheter ablation in the Chinese Atrial Fibrillation Registry between 2011 and 2019 were screened. A total of 441 patients with SCAD were matched with patients without SCAD in a 1:4 ratio. The primary endpoint was AF recurrence after single ablation. The composite secondary endpoints were thromboembolism, coronary events, major bleeding, all-cause death.Over a mean follow-up of 46.0 ± 18.9 months, the recurrence rate in patients with SCAD was significantly higher after a single ablation (49.0% vs. 41.9%, p = .03). The very late recurrence rate of AF in the SCAD group was also significantly higher than that in the control group (38.9% vs. 31.2%;p = .04). In multivariate analysis, adjusted with the female, smoking, duration of AF, previous thromboembolism, COPD, and statins, SCAD was independently associated with AF recurrence (adjusted HR, 1.19 [1.02-1.40], p = .03). The composite secondary endpoints were significantly higher in the SCAD group (12.70% vs. 8.54%, p = .02), mainly due to thromboembolism events (8.16% vs. 4.41%, p .01).SCAD significantly increased the risk of recurrence after catheter ablation of paroxysmal AF. The incidence of thromboembolic events after catheter ablation of paroxysmal AF in the patients with SCAD was significantly higher than that in those without SCAD.

Background To evaluate the impact of family history of atrial fibrillation (FAF) on postablation atrial tachyarrhythmia (AT) recurrence. Methods All the 8198 patients undergoing initial AF ablation registered in the Chinese Atrial Fibrillation Registry study were analyzed. FAF was defined as having first-degree relatives diagnosed as AF at age 65 years or younger, and before the time the case in this study was diagnosed. Cox proportional hazards models were used to evaluate the impact of FAF on postablation AT recurrence. Age, sex, body mass index, AF type, history of congestive heart failure, hypertension, diabetes mellitus, prior stroke/transient ischemic attack/systemic embolism, vascular diseases, use of contact force-sensing catheter, and completion of high school were adjusted. The definition of AT recurrence was any documented AF, atrial flutter, or AT lasting more than or equal to 30 s after 3 months blanking period. Results After a mean follow-up of 26.2 ± 19.6 months, 318 out of the 645 patients (49.3%) with FAF and 3339 out of the 7553 patients (44.2%) without FAF experienced AT recurrence, corresponding to annual recurrence rates of 22.8% and 20.2%, respectively. Patients with FAF had a significant higher risk of AT recurrence (adjusted hazard ratio 1.129, 95% confidence interval 1.005-1.267) in multivariable analysis. Moreover, FAF had a significant higher impact on AT recurrence in the subgroup of patients diagnosed with AF at age 50 years or younger (p for interaction = .036). Conclusion FAF is a risk factor for postablation AT recurrence. This is especially true in those with AF diagnosed at 50 years or younger.

Transforming growth factor-β1 signaling pathways are known to involve in the development of post-infarction fibrosis, a process characterized by the aberrant activation, proliferation, and differentiation of fibroblasts, as well as the unbalanced turnover of extracellular matrix proteins. Recent studies have shown that Lefty1, a novel member of TGF-β superfamily, acts as a brake on the TGF-β signaling pathway in non-cardiac tissues. However, its role in myocardial infarction (MI)–induced fibrosis and left ventricular remodeling has not been fully elucidated. Here, for the first time, we reported that Lefty1 alleviated post-MI fibroblast proliferation, differentiation, and secretion through suppressing p-Smad2 and p-ERK1/2 signaling pathways in vivo and in vitro. In MI mice or TGF-β1-treated neonatal rat cardiac fibroblasts (CFBs), the expression of Lefty1 was upregulated. Adenovirus-mediated overexpression of Lefty1 significantly attenuated TGF-β1-induced CFBs’ proliferation, differentiation, and collagen production. Using the adeno-associated virus approach, we confirmed that Lefty1 attenuates MI-induced cardiac injury, as evidenced by the decreased infarct size and preserved cardiac function. These results highlight the importance of Lefty1 in the prevention of post-MI fibrosis and may help identify potential targets for therapeutic intervention of cardiac fibrosis.

Aims This study sought to compare healthcare quality and 30 day, 90 day, and 1 year mortality rates among patients admitted to secondary and tertiary hospitals for heart failure (HF) in Beijing. Methods and results This study retrospectively enrolled patients hospitalized with a primary discharge diagnosis of HF during January 2014 to December 2015, from five tertiary and four secondary hospitals, in Beijing, China. Mortality data were extracted from Beijing Death Surveillance Database. HF healthcare quality indices were used to evaluate in‐hospital care. Associations between hospital level and mortality rates were assessed using generalized linear mixed models, adjusting for patients' baseline characteristics and intra‐hospital correlation. Data from 1413 patients (median [interquartile range] age = 74 [65–80] years, 52.7% female) from secondary hospitals and 1250 patients (median [interquartile range] age = 72 [61–79] years, 43.3% female) from tertiary hospitals were collected. Rates of left ventricular ejection fraction assessment (73.2% vs. 90.1%) and combined use of β‐blockers and angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers (30.1% vs. 49.3%) were lower in secondary hospitals than those in tertiary hospitals, respectively. Patients admitted to secondary hospitals had a higher 90 day mortality [10.8% vs. 5.0%; adjusted odds ratio (OR): 2.06; 95% confidence interval (CI): 1.10–3.84, P = 0.024 and a higher 1 year mortality rate [21.0% vs. 12.1%; adjusted OR: 1.64; 95% CI: 1.02–2.62, P = 0.039], but 30 day mortality rates were not significantly different (5.5% vs. 3.0%; adjusted OR: 1.49; 95% CI: 0.63–3.52, P = 0.368). Conclusions Worse quality of care for patients with HF in secondary hospitals was associated with higher 90 day and 1 year mortality rates. Improving care quality in secondary hospitals is crucial to improve prognosis of patients they served.

Transseptal passage is sometimes difficult to obtain. This study evaluates the feasibility and safety of a novel and easy transseptal puncture (TSP) technique named 2D2G (using two dilators and two guidewires) in patients with difficult TSP. Forty-four paroxysmal atrial fibrillation patients with difficult TSP were enrolled in this study. They were allocated to the 2D2G group or the conventional group in a 1:1 fashion. The primary endpoint in both groups was successful TSP without changing the puncture site or using auxiliary tools. The secondary endpoints were the safety, total transseptal puncture time, and ablation time. There were no differences in baseline demographic or clinical characteristics between the two groups. Successful LA access in the 2D2G group was 100% (vs. 64%, P

BACKGROUND Low-density lipoprotein cholesterol (LDL-C) reduction improves cardiovascular outcomes. This study investigates the relationship between lipid levels and outcomes in patients with nonvalvular atrial fibrillation by LDL-C quarters. MATERIAL AND METHODS Patients with atrial fibrillation were enrolled from 31 typical hospitals in China. Of 19 515 patients, 6775 with nonvalvular atrial fibrillation (NVAF) were followed for 5 years or until an event occurred. RESULTS Hyperlipidemia was not an independent risk factor for stroke/thromboembolism and cardiovascular mortality among patients with NVAF (hazard ratio 0.82, 95% CI 0.7-0.96, P=0.82). When patients were divided into quartiles according to LDL-C levels at the time of enrollment (Q1,1.95; Q2, 1.95-2.51; Q3, 2.52-3.09; and Q4,3.09 mmol/L), as LDL-C increased, events tapered off according to Kaplan-Meier curves for patients who were without oral anticoagulants and off statins (non-OAC; log-rank=8.3494, P=0.0393) and for those with oral anticoagulants (OAC; log-rank=6.7668 P=0.0797). This relationship was stronger for patients who were without OAC treatment and off statins than for those with OAC treatment. The relationship was not significant in patients with or without OAC and on statins (log-rank=2.5080, P=0.4738). This relationship also existed in patients with CHA₂DS₂-VASc scores2 (log-rank=5.893, P=0.1167). For those with CHA2DS2-VASc scores ≥2 (log-rank=6.6163, P=0.0852), the relationship was stronger. CONCLUSIONS In patients with NVAF using standard or no lipid-lowering medication, low plasma LDL-C levels were related to an increased risk of stroke/thromboembolism and cardiovascular mortality.

BACKGROUND AND OBJECTIVE Atrioesophageal fistula (AEF) is a rare but devastating complication with high mortality post atrial fibrillation (AF) ablation. The purpose of current study was to determine the epidemiology, clinical features, pathogenesis, and management of AEF after AF ablation. METHODS AND RESULTS Patients with diagnosed AEF were included and retrospectively analyzed according to the registry of 11 centers in China from January 2010 to December 2019. A total of 16 AEF cases were identified from 44 794 patients who received a left atrial ablation procedure (0.035% per procedure). The interval from procedure to clinical onset of AEF averaged 18.3 days (3-39 days). The fever ranked the most common symptom, occurred in 14 of the 16 cases, followed by neurological deficits (n = 11), chest pain (n = 5), and hematemesis (n = 4). Patients undergoing surgical repair had a better prognosis compared to those receiving nonsurgical management ([4 of 8] 50.0% vs [8 of 8] 100%, P

This study aimed to verify the reliability of ablation index (AI) for ablation lesion estimating with different settings for radiofrequency (RF) parameters: power, impedance, contact angles, irrigation rate, temperature of irrigation saline, and irrigation solution. RF ablations (N = 66) were performed on ex vivo porcine left ventricle submerged in 37 °C saline. The aforementioned ablation parameters were changed to measure whether the size of the ablation lesion was consistent at a fixed AI value of 500. The maximum lesion diameter (r = - 0.631, P = 0.028), depth (r = - 0.896, P 0.001), and volume (r = - 0.745, P 0.005) were significantly reduced with an increase of the impedance. The lesion depth (P 0.05) and the lesion volume (P 0.05) were significantly larger with glucose irrigation than saline irrigation. In conclusion, at a fixed AI value, impedance and irrigation solution have impact on the ablation lesions, which could affect the accuracy of AI formula to estimate ablation lesion size. Graphical abstract.

Background Right free-wall (RFW) accessory pathway (AP) with branched atrial insertions is a rare, underrecognized AP that may be associated with initial ablation failure. Objective The purpose of this study was to investigate the clinical and electrophysiological characteristics of this AP. Methods From January 2011 to March 2018, 10 patients identified with branched RFW-AP were enrolled in this study, and 30 consecutive patients with conventional RFW-APs served as control group. Right atrium (RA) was activation-mapped and 3-dimensionally reconstructed during AP-mediated orthodromic tachycardia or right ventricular pacing. Atrial insertions were defined as the earliest breakout sites, and their relationship with the tricuspid annulus (TA) were described and analyzed. Results An average of 3 separate atrial insertions on the atrial side were documented among these 10 cases (5 female and 5 male; mean age 38.0 ± 13.9 years). All atrial insertions were away from the TA. The nearest atrial insertions averaged 15.9 ± 3.4 mm away from the TA, and the farthest atrial insertions were 22.6 ± 5.7 mm away from the TA. Anterograde and retrograde AP conduction remained unaffected after ablation of the first earliest breakout site but were eliminated by ablating all insertions after an average of 2.5 (range 2–2.5) remaps, 3 sites of ablation (range 2.5–4.5), 21 (range 15.5–37.8) radiofrequency applications, and 659.5 (range 464.3–1144.3) seconds of radiofrequency ablation duration. After 12-month follow-up, no patients reported AP conduction recovery or recurrent tachycardia. Conclusion RFW-AP with branched atrial insertions is an atypical AP variant and featured by >1 distinct atrial insertions on atrial side. Stepwise ablation rather than single focal ablation is required to eliminate all retrograde conduction.

Objective To investigate the feasibility and safety of wire-guided pericardial access without contrast. Methods From January 2014 to February 2019, patients who received epicardial mapping and ablation of ventricular tachycardia in the Beijing Anzhen Hospital were entered into the current study. They were divided into contrast-guided access group or wire-guided access group according to the pericardial puncture technique used. The baseline variables, procedure parameters, complications were collected and compared. Results During the study period, a consecutive of 73 patients received epicardial access. The initial 32 patients received contrast-guided puncture with success achieved in 30 patients, the remaining 41 patients underwent wire-guided puncture with success achieved in 40 patients (30/32 and 40/41, P = .581). Fluoroscopy time (4.45 ± 0.52 and 4.38 ± 0.46 minutes, P = .891) and access time (5.14 ± 0.58 and 5.34 ± 0.50 minutes, P = .657) were comparable between the two groups. Inadvertent right ventricular puncture occurred more commonly in the contrast-guided group (5/32 and 1/41, P = .038). Though more pericardial effusions (2/32 and 1/41, P = .575), tamponade (2/32 and 1/41, P = .575), and surgical repair (1/32 and 0/41, P = .432) occurred in the contrast-guided group, they reached no statistical difference. Conclusion Wire-guided pericardial puncture exhibits better safety and similar success rates to contrast-guided technique with a trend towards less complications.

Background Data on management of maternal arrhythmia among Chinese were limited. Radiofrequency catheter ablation (RFCA) proved to be a reliable treatment choice for sustained tachyarrhythmia but it has rarely been performed during pregnancy due to radiation exposure. Objective To investigate the incidence of idiopathic sustained maternal arrhythmia and the feasibility of RFCA in the pregnant patients without fluoroscopy. Methods From January of 2015 to December of 2018, the medical records on pregnancy-related admissions in Beijing Anzhen Hospital (Beijing, China) were retrospectively analyzed. Patients who had sustained tachyarrhythmia episodes without structural heart disease were identified. Catheter ablation was performed in those with drug resistant and severely frequent tachyarrhythmia under the guidance of electroanatomical mapping system and intracardiac echocardiography catheter (ICE), if appropriate. Results During the study period, 12 584 consecutive pregnant women were admitted for pregnancy-related reasons, 156 (1.2%) of them were identified as sustained maternal tachyarrhythmia. Twenty-eight patients (age 21-37 years) received catheter ablation because the arrhythmias were drug resistant and severely frequent. The RFCA was successfully performed in all patients with zero fluoroscopy after 72.4 ± 24.7 min. Transseptal puncture was performed in 11 patients under the guidance of ICE. In a median of 37 (interquartile range [IQR]: 34-39) weeks' pregnancy, 28 healthy fetuses were delivered. No cardiac-related adverse event occurred during delivery. During later follow-up, all patients were free of arrhythmia, and all the infants were well developed. Conclusion Sustained maternal tachyarrhythmia is not uncommon in the clinical practice. To those with drug resistant and severely frequent arrhythmia, RFCA with zero fluoroscopy could be safely performed with acceptable efficacy.

BACKGROUND: Degradation of pro-inflammatory macrophage-mediated connexin 43 (Cx43) plays an important role in post-myocardial infarction (MI) arrhythmogenesis, microRNA (miR)-155 produced by macrophages has been shown to mediate post-MI effects. We hypothesized that miR-155 inhibition attenuated MI-induced Cx43 degradation by reducing pro-inflammatory macrophage activation. METHODS: MI was induced by permanent ligation of the left anterior descending coronary artery in male C57BL/6 mice. Lipopolysaccharide (LPS)-stimulated mice bone marrow-derived macrophages (BMDMs) and hypoxia-induced neonatal rat cardiomyocytes (NRCMs) were used in vitro models. qRT-PCR, Western-blot and immunofluorescence were used to analyze relevant indicators. RESULTS: The expression levels of miR-155, interleukin-1 beta (IL-1β), and matrix metalloproteinase (MMP)7 were higher in MI mice and LPS-treated BMDMs than in the sham/control groups, treatment with a miR-155 antagomir reversed these effects. Moreover, miR-155 inhibition reduced ventricular arrhythmias incidence and improved cardiac function in MI mice. Cx43 expression was decreased in MI mice and hypoxia-exposed NRCMs, and hypoxia-induced Cx43 degradation in NRCMs was reduced by application of conditioned medium from LPS-induced BMDMs treated with the miR-155 antagomir, but increased by conditioned medium from BMDMs treated with a miR-155 agomir. Importantly, NRCMs cultured in conditioned medium from LPS-induced BMDMs transfected with small interfering RNA against IL-1β and MMP7 showed decreased hypoxia-mediated Cx43 degradation, and this effect also was diminished by BMDM treatment with the miR-155 agomir. Additionally, siRNA-mediated suppressor of cytokine signaling 1 (SOCS1) knockdown in LPS-induced BMDMs promoted Cx43 degradation in hypoxia-exposed NRCMs, and the effect was reduced by the miR-155 inhibition. CONCLUSIONS: MiR-155 inhibition attenuated post-MI Cx43 degradation by reducing macrophage-mediated IL-1β and MMP7 expression through the SOCS1/nuclear factor-κB pathway.

INTRODUCTION Linear ablation in addition to pulmonary vein antrum isolation (PVAI) has failed to improve the success rate for persistent atrial fibrillation (PeAF), due to incomplete block of ablation lines, especially in the mitral isthmus (MI). METHODS AND RESULTS The study enrolled 191 patients (66 in group 1 and 125 in group 2). In group 1, ethanol infusion into the vein of Marshall was first performed, followed by radiofrequency (RF) applications targeting bilateral PVAI and bidirectional block in the roofline, cavotricuspid isthmus, and MI. In group 2, PVAI and the three linear ablations were completed using only RF energy. MI block was achieved in 63 (95.5%) and 101 (80.8%) patients in groups 1 and 2, respectively (p = .006). Patients in group 1 had shorter ablation time for left pulmonary vein antrum (8.15 vs. 12.59 min, p

This study sought to investigate whether left ventricular (LV) fibrosis quantified by T1 mapping can be used as a biomarker to predict outcome in patients with atrial fibrillation (AF) and heart failure (HF). 108 patients with AF and HF were included in this study. They underwent cardiac magnetic resonance, including T1 mapping sequence to assess LV fibrosis between May 2014 to May 2016. Patients received catheter ablation for AF and pharmacological treatment for HF. The primary endpoint was a composite adverse outcome of cardiac death, subsequent HF or stroke, subsequent HF was the secondary endpoint. During follow up (median: 23 months, Q1-Q3: 11 to 28 months), 1 cardiac death, 12 strokes, and 42 HF episodes occurred. LV extracellular volume fraction (ECV) was predictive of composite adverse outcome and subsequent HF (all p

Introduction The outcomes of atrial fibrillation (AF) ablation remain suboptimal. It is important to identify which AF patients will most likely benefit from ablation and who are more likely to show treatment failure, especially in those with structural heart disease such as hypertrophic cardiomyopathy (HCM). Methods and results We enrolled 120 HCM patients who underwent primary AF ablation (48 with persistent AF). Preprocedural QTc was measured and corrected using the Bazett's formula, and the distribution of fragmentation of the QRS complex (fQRS) was recorded. Arrhythmia recurrence was defined as any kind of documented atrial tachyarrhythmia of more than 30 seconds. Overall, arrhythmia recurrence occurred in 69 patients after 13.4 months' follow-up. fQRS was present in 71 (59.17%) patients and was most commonly (81.69%) observed in the inferior leads. QTc more than 448 ms could predict arrhythmia recurrence with a sensitivity of 68.1% and specificity of 68.6%. Patients with QTc more than 448 ms (hazard ratio [HR]: 1.982; 95% confidence interval [CI]: 1.155-3.402; P = .013) or those with fQRS+ (HR: 1.922; 95% CI: 1.151-3.210; P = .012) were at an increased risk of recurrence. A combination of fQRS+ and QTc more than 448 ms was superior to fQRS or QTc alone in predicting arrhythmia recurrence. Conclusion In patients with HCM undergoing AF ablation, QTc prolongation, specifically >448 ms, and presence of fQRS are independent risk factors for arrhythmia recurrence at follow-up. The combination of these two parameters has greater predictive value and would help to identify patients who are at the highest risk of procedural failure.

Objectives To investigate the relationship between coronary artery calcification and calcium deposition in cardiomyocytes. Methods Patients who underwent valve replacement plus surgical ablation for atrial fibrillation, together with left atrial appendage resection, were included. Coronary artery calcification (CAC) score was evaluated prior to surgery using dual-source computed tomography. Samples of left atrial appendage tissue were collected to analyse the following indicators: calcium deposition, alkaline phosphatase activity, calcium content, protein levels of runt-related transcription factor 2 (Runx2), osteopontin and β-catenin, and mRNA levels of osteopontin, endothelin and ghrelin. Relationships between CAC score and various indicators were analysed by univariate logistic or linear regression. Results Out of tissue from eight patients, CAC score was not correlated with cardiomyocyte calcification (odds ratio [OR] 0.984 and OR 0.983; von Kossa or alizarin red staining, respectively). CAC score showed an inverse linear correlation with Runx2 protein (β = –0.75), but was not correlated with osteopontin (β = –0.52) or β-catenin protein (β = –0.56), mRNA levels of osteopontin, endothelin and ghrelin (β = 0.13, 0.02, and 0.02, respectively), alkaline phosphatase activity (β = 0.56), or calcium content (β = –0.22). Conclusions Coronary artery calcification was not correlated with calcium deposition in cardiomyocytes.

Impact of body mass index (BMI) on all-cause mortality in atrial fibrillation (AF) patients remains controversial. A total of 10,942 AF patients were prospectively enrolled and categorized into four BMI groups: underweight (BMI

Background It is unclear whether catheter ablation (CA) for atrial fibrillation (AF) affects the long-term prognosis in the elderly. This study aims to evaluate the relationship between CA and long-term outcomes in elderly patients with AF. Methods Patients more than 75 years old with non-valvular AF were prospectively enrolled between August 2011 and December 2017 in the Chinese Atrial Fibrillation Registry Study. Participants who underwent CA at baseline were propensity score matched (1:1) with those who did not receive CA. The outcome events included all-cause mortality, cardiovascular mortality, stroke/transient ischemic attack (TIA), and cardiovascular hospitalization. Results Overall, this cohort included 571 ablated patients and 571 non-ablated patients with similar characteristics on 18 dimensions. During a mean follow-up of 39.75 ± 19.98 months (minimum six months), 24 patients died in the ablation group, compared with 60 deaths in the non-ablation group [hazard ratio (HR) = 0.49, 95% confidence interval (CI): 0.30-0.79, P = 0.0024]. Besides, 6 ablated and 29 non-ablated subjects died of cardiovascular disease (HR = 0.25, 95% CI: 0.11–0.61, P = 0.0022). A total of 27 ablated and 40 non-ablated patients suffered stroke/TIA (HR = 0.79, 95% CI: 0.48–1.28, P = 0.3431). In addition, 140 ablated and 194 non-ablated participants suffered cardiovascular hospitalization (HR = 0.84, 95% CI: 0.67–1.04, P = 0.1084). Subgroup analyses according to gender, type of AF, time since onset of AF, and anticoagulants exposure in initiation did not show significant heterogeneity. Conclusions In elderly patients with AF, CA may be associated with a lower incidence of all-cause and cardiovascular mortality.

Atrial fibrillation (AF) is one of the most common tachyarrhythmias observed in the clinic and is characterized by structural and electrical remodelling. Atrial fibrosis, an emblem of atrial structural remodelling, is a complex multifactorial and patient‑specific process involved in the occurrence and maintenance of AF. Whilst there is already considerable knowledge regarding the association between AF and fibrosis, this process is extremely complex, involving intricate neurohumoral and cellular and molecular interactions, and it is not limited to the atrium. Current technological advances have made the non‑invasive evaluation of fibrosis in the atria and ventricles possible, facilitating the selection of patient‑specific ablation strategies and upstream treatment regimens. An improved understanding of the mechanisms and roles of fibrosis in the context of AF is of great clinical significance for the development of treatment strategies targeting the fibrous region. In the present review, a focus was placed on the atrial fibrosis underlying AF, outlining its role in the occurrence and perpetuation of AF, by reviewing recent evaluations and potential treatment strategies targeting areas of fibrosis, with the aim of providing a novel perspective on the management and prevention of AF.

Hepatitis C virus infection (HCV) may be associated with a greater risk of cardiovascular disease (CVD), and the evidence for whether antiviral therapy for HCV could reduce the risk of CVD events is inconsistent. The aim of this meta-analysis was to investigate the association between anti-HCV treatment and the risk of CVD. We searched PubMed, EMBASE and Cochrane Library databases from inception to 20 August 2020. The pooled hazard ratio (HR) with 95% confidence interval (CI) of the risk of CVD events [any CVD, coronary artery disease (CAD) and stroke] was calculated using the random-effects model. A total of eleven studies, including 309,470 subjects, were enrolled in this meta-analysis. Among those, four studies reported on any CVD between anti-HCV-treated and anti-HCV-untreated patients, five studies reported on CAD, and five studies reported on stroke. Also, five studies reported on any CVD between patients with sustained virological response (SVR) and without SVR. Overall, antiviral therapy for HCV was associated with a reduced risk of any CVD (HR = 0.64, 95% CI: 0.50-0.83), CAD (HR = 0.73, 95% CI: 0.55-0.96) and stroke (HR = 0.74, 95% CI: 0.64-0.86). Besides, we found that SVR was associated with a significant decrease in any CVD compared with non-SVR (HR = 0.74, 95% CI: 0.60-0.92). In conclusion, this meta-analysis demonstrated that antiviral therapy for HCV was associated with a reduced risk of CVD events. In addition, the risk of CVD events was lower in individuals with SVR compared with those without SVR.

Sacubitril/valsartan (SAC/VAL) prevents angiotensin II (AngII) from binding AT1-R and blocks degradation of natriuretic peptides. Despite its efficacy in reducing ventricular fibrosis and preserving cardiac functions, which has been extensively demonstrated in myocardial infarction or pressure overload models, few studies have been conducted to determine whether SAC/VAL could attenuate atrial fibrosis and decrease atrial fibrillation (AF) susceptibility. Our study provided evidence for the inhibition of atrial fibrosis and reduced susceptibility to AF by SAC/VAL. After 28 days of AngII continuous subcutaneous stimulation, rats in SAC/VAL group exhibited reduced extent of atrial fibrosis, inhibited proliferation, migration, and differentiation of atrial fibroblasts, and decreased susceptibility to AF. We further found that inhibition of p-Smad2/3, p-JNK, and p-p38MAPK pathways is involved in the role of SAC/VAL on AngII-induced atrial fibrosis in vivo. These results emphasize the importance of SAC/VAL in the prevention of AngII-induced atrial fibrosis and may help to enrich the options for AF pharmacotherapy.

Background: Sacubitril/valsartan (SAC/VAL), combined inhibitors of angiotensin receptor (AT-R) and neprilysin receptor, prevents Angiotensin Ⅱ (AngⅡ) from binding AT1-R and blocks degradation of natriuretic peptides. Despite its efficacy in reducing ventricular fibrosis and preserving cardiac functions, which has been extensively demonstrated in myocardial infarction or pressure overload models, few studies have been conducted to determine whether SAC/VAL could attenuate atrial fibrosis and decrease atrial fibrillation (AF) susceptibility. Methods: Sprague-Dawley rats were divided into three groups after implantation of an osmotic pump preloaded with AngⅡ and received corn oil, VAL, or SAC/VAL treatment for 28 days. Electrophysiological study was performed to determine inducibility and duration of AF. Echocardiography was performed before and 28 days after osmotic mini-pump implantation to evaluate cardiac functions. Enzyme-linked immunosorbent assay was perfomed to detect the serum concentration of atrial natriuretic peptide (ANP), N-terminal pro-brain natriuretic peptide (NT-proBNP) and AngⅡ. Masson staining was performed to determine the extent of interstitial fibrosis. Immunohistochemical, and immunofluorescence staining as well as transwell and MTT assay were also performed. Western blot analysis was perfomed to figure out how SAC/VAL exerts its anti-fibrosis effects in atriums.Results: After 28 days of AngⅡ stimulation, rats in SAC/VAL group exhibited reduced reduced extent of atrial fibrosis, inhibited proliferation, migration, and differentiation of atrial fibroblasts and decreased susceptibility to atrial fibrillation. We further found that SAC/VAL exerted its effect on AngⅡ-induced atrial fibrosis by inhibiting the p-Smad2/3, p-JNK, and p-p38 MAPK signaling pathways in vivo. Conclusions: Our study provided experimental evidence for the inhibition of atrial fibrosis and reduced susceptibility to AF by SAC/VAL. These results emphasize the importance of SAC/VAL in the prevention of AngⅡ-induced atrial fibrosis and may help to enrich the options for atrial fibrillation pharmacotherapy.

Introduction Catheter ablation for atrial fibrillation (AF-CA) in patients with situs inversus dextrocardia (SID) can be challenging because of the contrary anatomy and associated anomalies. Cases and literature regarding AF-CA in SID are rare and provide little information. Our study aims to present an improved procedure, ablation strategies, and evaluate the safety and outcomes of AF-CA in patients with AF and SID. Methods A total of 10 patients with AF-SID (mean age, 60.4 ± 15.7 years; six paroxysmal AF, four persistent atrial fibrillation [PeAF]) were enrolled. For the improved procedure, images obtained by preacquired computed tomography and three-dimensional electroanatomical mapping, integrating intracardiac echocardiography, and x-ray imaging data are necessary to optimize the transseptal puncture and ablation procedure. Results All patients successfully underwent 13 AF-CA procedures without complications, including three patients received repeat procedures. However, two PeAF patients presented sick sinus syndrome (SSS) after the AF-CA procedure, and one underwent permanent pacemaker implantation therapy during hospitalization. During the follow-up period (6-72 months), the outcomes were not favorable: three patients (30%) maintained sinus rhythm (SR) after the initial procedure; after repeated procedures, the overall SR rate was 40% (four patients). Conclusion With the improved strategy, AF-CA can be safely and effectively performed with low radiation exposure in patients with SID. However, the long-term outcomes were not favorable, even when managed at a tertiary center by a team of specialists. Moreover, patients with PeAF might also have masked SSS, which should be carefully considered.

Transforming growth factor-β1 signaling pathways are known to involve in the development of post-infarction fibrosis, a process characterized by the aberrant activation, proliferation, and differentiation of fibroblasts, as well as the unbalanced turnover of extracellular matrix proteins. Recent studies have shown that Lefty1, a novel member of TGF-β superfamily, acts as a brake on the TGF-β signaling pathway in non-cardiac tissues. However, its role in myocardial infarction (MI)-induced fibrosis and left ventricular remodeling has not been fully elucidated. Here, for the first time, we reported that Lefty1 alleviated post-MI fibroblast proliferation, differentiation, and secretion through suppressing p-Smad2 and p-ERK1/2 signaling pathways in vivo and in vitro. In MI mice or TGF-β1-treated neonatal rat cardiac fibroblasts (CFBs), the expression of Lefty1 was upregulated. Adenovirus-mediated overexpression of Lefty1 significantly attenuated TGF-β1-induced CFBs' proliferation, differentiation, and collagen production. Using the adeno-associated virus approach, we confirmed that Lefty1 attenuates MI-induced cardiac injury, as evidenced by the decreased infarct size and preserved cardiac function. These results highlight the importance of Lefty1 in the prevention of post-MI fibrosis and may help identify potential targets for therapeutic intervention of cardiac fibrosis. Graphical abstract.

Background Catheter ablation of perimitral atrial tachycardia (PMAT) is challenging. Epicardial conduction of the Marshall bundle (MB) across the mitral isthmus (MI) remains an important cause of recurrent tachycardia. The role of ethanol infusion into the vein of Marshall (EI-VOM) for PMAT has not been fully elucidated. Methods The study enrolled 28 consecutive patients with recurrent PMAT after atrial fibrillation (AF) ablation. Conventional PMAT (group 1, n = 15) and MB-related PMAT (group 2, n = 13) were diagnosed by detailed activation mapping and entrainment mapping. VOM venography and EI-VOM were first performed, and additional ablation was performed if necessary. Results The VOM was accessible in 24 (85.7%) patients (12 [80%] in group 1 and 12 [92.3%] in group 2). Patients with MB-related PMAT were more responsive to EI-VOM (as shown by PMAT termination or tachycardia cycle length prolongation) (92.4% vs 53.3%, P = .038). In the 16 patients requiring additional ablation after EI-VOM, all residual MI conduction gaps were located on the annular side of the MI. At the end of the procedure, MI bidirectional block was achieved in 14 (93.3%) patients in group 1 and in 12 (92.3%) patients in group 2 (P = 1.000). After a mean follow-up of 7.5 ± 3.1 months, three (10.7%) patients had recurrent AT. Conclusions EI-VOM is feasible and effective in the treatment of PMAT after AF ablation, especially in patients with MB-related PMAT.

Background Novel coronavirus disease 2019 (COVID-19) has become a worldwide pandemic and precise fatality data by age group is needed urgently. This study to delineate the clinical characteristics and outcome of COVID-19 patients aged ≥75 years and identify the risk factors of in-hospital death. Methods A total of 141 consecutive patients aged ≥75 years who were admitted to the hospital between 12th and 19th February 2020. In-hospital death, clinical characteristics and laboratory findings on admission were obtained from medical records. The final follow-up observation was on the 31st March 2020. Results The median age was 81 years (84 female, 59.6%). Thirty-eight (27%) patients were classified as severe or critical cases. 18 (12.8%) patients had died in hospital and the remaining 123 were discharged. Patients who died were more likely to present with fever (38.9% vs. 7.3%); low percutaneous oxygen saturation (SpO2) (55.6% vs. 7.3%); reduced lymphocytes (72.2% vs. 35.8%) and platelets (27.8% vs. 4.1%); and increased D-dimer (94.4% vs. 42.3%), creatinine (50.0% vs. 22.0%), lactic dehydrogenase (LDH) (77.8% vs. 30.1%), high sensitivity troponin I (hs-TnI) (72.2% vs. 14.6%), and N-terminal pro-brain natriuretic peptide (NT-proBNP) (72.2% vs. 6.5%; all P P = 0.044), body temperature > 37.3 °C (OR = 80.5, 95% CI 4.6 to 1407.6, P = 0.003), SpO2 ≤ 90% (OR = 70.1, 95% CI 4.6 to 1060.4, P = 0.002), and NT-proBNP> 1800 ng/L (OR = 273.5, 95% CI 14.7 to 5104.8, P Conclusions In-hospital fatality among elderly COVID-19 patients can be estimated by sex and on-admission measurements of body temperature, SpO2, and NT-proBNP.

Background Atrial fibrillation (AF) is common in abdominal solid organ transplant recipients and a cause of morbidity and mortality in this population. However, the outcomes of catheter ablation (CA) in transplant recipients with AF remain unclear. This study aimed to elucidate the outcomes of CA in renal and hepatic transplant recipients. Methods and results Between 2015 and 2019, 14 transplant recipients (nine with kidney transplantation and five with liver transplantation) were enrolled from among 10,741 AF patients and underwent CA at Anzhen Hospital. Another 56 patients matched by age, sex, and AF type were selected as the control group (four controls for each transplant recipient). During a mean follow-up of 30.0 ± 13.3 months after the initial procedure, 10 (71.4%) of the transplant patients, compared to 41 (73.2%) of the control patients, remained free from AF recurrence (p = 1.000). A repeated procedure was performed in one transplant patient and in six control subjects. Consequently, 11 (78.6%) of the transplant patients, compared to 46 (82.1%) of controls, were in sinus rhythm after the repeated ablation (p = .715). Notably, Kaplan-Meier analysis did not demonstrate any significant differences in the atrial arrhythmia-free rate after the initial and repeated procedure between the two groups. Vascular complications were identified in one transplant patient and two control subjects, while no life-threatening complications were observed in either group. There was no transient allograft dysfunction in transplant recipients after CA. Conclusion CA is safe and effective in abdominal solid transplant recipients, and maybe an optimal therapeutic strategy for this group.

The moderator band (MB) is an endocavitary structure with only 2 exits to the bulk of the ventricular myocardium. Whether this may lead to specific electrophysiological characteristics remains unknown.The purpose of this study was to investigate electrocardiographic (ECG), activation, and pace mapping characteristics of MB-originated ventricular arrhythmias (VAs).Mapping and ablation of MB-VAs were performed in 12 patients under the guidance of a 3-dimensional electroanatomic mapping system and intracardiac echocardiography and ECG, and mapping data were analyzed. Of these patients, 11 underwent pace mapping study of 6 sites around the MB and the QRS morphology was compared.The earliest activation site was free wall (FW) insertion in 8 patients (66.7%) and MB body in 4 patients (33.3%), preceding the QRS onset by 17.8±4.7 ms, and Purkinje-like potential was observed in 6 (50.0%). VAs were eliminated at the earliest activation site in the procedure, but recurrence was documented in 2 cases (16.7%) during a follow-up of 13.4±7.8 months. Pacing QRS complex from the MB was characterized by short QRS duration (P.001), short intrinsicoid deflection time (P.001), later precordial transition (P=.025), and notch on the descending limb of the inferior leads (P.001) as compared with pacing from the adjacent anterior-lateral FW, and that notch could also differentiate MB from the anterior papillary muscle (P=.027). However, pacing QRS is identical between the MB body and the FW insertion in 11 of 11 patients and between the septal insertion and the MB body in 7 of 11 patients.Bidirectional conduction via the 2 exits during MB-VAs contributed to distinct ECG and electrophysiological characteristics, while pace mapping is of limited value in defining the ablation target.

Background: Atrial fibrillation (AF) is associated with high risk of mild cognitive impairment (MCI) and dementia. However, feasible and simple instruments that facilitates regular assessment of cognitive status in AF patients remain underdeveloped. Methods: Cognitive function of 136 AF patients was first evaluated using T-MoCA. Cognitive function of 101 patients was then assessed through in-person interview by physicians who are blinded to telephone interview results, using both Clinical Dementia Rating (CDR) and Mini-Mental Status Evaluation (MMSE). Using CDR=0.5 as a reference standard, the ability of T-MoCA and MMSE to discriminate cognitive dysfunction, stratified by education level, was tested by receiver-operating curve (ROC) analysis. Net reclassification index was calculated for comparison between the performance of T-MoCA and MMSE. Results: Thirty-five MCI patients were identified as MCI using the criteria of CDR=0.5. The areas under the ROC curve of T-MoCA were 0.80 (0.71-0.89), 0.83 (0.71-0.95), and 0.85 (0.64-0.92) for all patients, patients with high educational level, and patients with low education level, respectively. The optimal threshold was achieved at 16/17 with a sensitivity of 85.7% and a specificity of 69.7% in overall patients, 15/16 with a sensitivity of 88.2% and a specificity of 64.5% in the low educational level patients, and 16/17 with a sensitivity of 77.8% and a specificity of 87.9% in the high educational level patients. Compared to the criterion MMSE≤27 and MMSE norms for the Chinese community elderly, stratified T-MoCA threshold improves correct classification by 23.7% (p=0.033) and 30.3% (p=0.020) respectively. Conclusion: T-MoCA is a feasible and effective method for MCI screening in patients with AF.

BACKGROUND: Left ventricular (LV) extracellular volume fraction (ECV) provides prognostic information in patients with variety of cardiomyopathies. However, data on the clinical significance of LV ECV in patients with atrial fibrillation (AF), especially in patients without replacement fibrosis are sparse. This study sought to investigate whether the presence of LV fibrosis identified by cardiac magnetic resonance (CMR) ECV quantification would independently predict the recurrence of AF after first catheter ablation (CA) in patients with AF. METHODS: A total of 130 consecutive patients who were referred for CA of AF underwent CMR examination prior to ablation. LV function, T1 mapping derived LV ECV, LV late gadolinium enhancement (LGE) were assessed. Patients were followed for arrhythmia recurrence after the CA procedure. RESULTS: Of 130 AF patients, 65 patients had paroxysmal AF, and 65 patients had persistent AF. There were 50 AF recurrences over a median follow-up period of 13 months. LV ECV were significantly higher in patients with recurrent AF compared to those with no recurrence (30.4%±3.3% vs. 27.4%±2.9%, P