Abstract Aim and objectives The aim of this study was to assess the relationship between vitamin D deficiency and extent of success of cardioversion in patients with lone atrial fibrillation (AF). Patients and Methods This observational cross-sectional study included 50 patients (18-60 years old) who presented to the cardiology department of Ain Shams university hospitals with lone atrial fibrillation with structurally normal heart for cardioversion after fulfilling the inclusion criteria, considering that failure of cardioversion was defined as failure of restoration to normal sinus rhythm after applying the cardioversion protocol that is being used in our cardiology department in Ain Shams University hospitals. Serum vitamin D level on admission was sampled for all patients before cardioversion, and cardioversion was assessed after then whether success or failure. Cardioversion success was restoration of normal sinus rhythm and that the patient was discharged in sinus rhythm. Cardioversion protocol that was being used was applied as Loading dose of Intravenous (IV) Amiodarone of 300 mg diluted in 250 ml 5% dextrose over 30-60 minutes, then follow up dose of 900 mg IV over 24 hours diluted in 500-1000 ml of normal saline, then if failed, application of biphasic synchronized direct current electrical cardioversion at 200 joules at anteriorlateral electrode positions. Results The success rate of cardioversion was 80% (40 out of 50) in all the patients presented, and the failure rate was 20% (10 out of 50). In the success group, majority of patients 23 (57.5%) had sufficient Vitamin D levels (≥30 ng/ml), 15 patients (37.5%) had insufficient vitamin D levels (21-29 ng/ml) and 2 patients (5%) had deficient vitamin D levels (≤20 ng/ml). Meanwhile, in the failure group, the majority of patients 8 (80%) had deficient vitamin D levels (≤20 ng/ml), 1 patient (10%) had insufficient vitamin D level (21-29 ng/ml), and 1 patient (10%) had sufficient vitamin D level (≥30 ng/ml).This difference was statistically significant with a P value of < 0.01. Vitamin D level measured (25-OH vitamin D) had values of mean ± SD of 29.41 ± 4.89 ng/ml in the success group vs 19.22 ± 4.68 ng/ml in the failure group, which was statistically significant with a P value of <0.01. A-P (antero-posterior) LAD (left atrial diameter) measured in parasternal long axis view during routine pre-cardioversion work-up study by echocardiography that has been done, had values of mean ± SD of 37.60 ± 3.20 mm in the success group vs 37.80 ± 2.86 mm in the failure group, which was statistically non- significant with a P value of 0.858. There was not a statistically significant difference between the 2 groups regarding age, sex, BMI, smoking, duration of AF(duration of onset of symptoms), number of previous trials of cardioversion, previous antiarrythmic drugs that have been administered and heart rate at time of cardioversion. Conclusion Failure rate of cardioversion was found to be higher in patients with vitamin D deficiency in comparison to patients with sufficient and insufficient vitamin D levels. Abbreviations AF: Atrial Fibrillation; A-P: Antero-posterior; BMI: Body mass index; LAD: Left atrial diameter; SD: Standard deviation

10.1093/qjmed/hcad069.137

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Safety and outcome of cryoballoon ablation versus radiofrequency catheter ablation of the pulmonary veins in patients with paroxysmal atrial fibrillation

QJM (2020)

Omar Riad T Wong Ahmed Ali Mazen Tawfik Ibrahim M A Abdelhamid

Abstract Background Pulmonary vein isolation (PVI) has become the mainstay of catheter ablation of atrial fibrillation (AF). There are two commonly used methods to isolate the pulmonary veins, either point-by-point delivery of circumferential lesion sets around ipsilateral pulmonary veins using radiofrequency energy, or the application of the cryoballoon to the pulmonary vein antrum with occlusion of the vein ostium. The cryoballoon has proven to be a reliable alternative to radiofrequency ablation in acute and long-term freedom from AF. We describe our results using both modalities. Aim and Objectives to compare the safety and efficacy of cryoballoon (CB) ablation and radiofrequency (RF) ablation in treatment of paroxysmal atrial fibrillation. Patients and Methods Forty-four consecutive patients having paroxysmal AF underwent PVI using the second generation cryoballoon were compared to a retrospective cohort of 69 patients who had radiofrequency induced PVI, either by conventional RF catheter (n = 32), or a contact-force sensing-catheter (n = 37). The study took place at Ain Shams university hospitals and Royal Brompton & Harefield NHS trust. Patient data, procedural data and follow up data- at 3, 6 and 12 months- were collected and analysed. Recurrence was defined as documented AF or atrial arrhythmias with duration exceeding 30 seconds, either by 12 lead ECG or an ambulatory monitoring device. Results A total of 113 patients were studied. The mean age was 53.84 ± 15.01 for the CB group and 55.78 ± 14.84 for the RF group and females representing 40.9% vs 34.8% respectively. The mean procedural times in minutes were significantly less in the CB group (94.37 ± 39.32 vs 184.57 ± 88.19, p < 0.0001), while the median fluoroscopy times were similar [30 (11.04 - 40) vs 37.25 (14.2 - 70), p = 0.172]. Procedural complications were comparable between the two groups (p = 0.06) with 1 patient (2.3%) having long term phrenic nerve paresis. At 1 year follow up, after an initial 90-day blanking period, recurrence rate of CB was similar to RF (27.3% vs 30.4% respectively, p = 0.719), the Kaplan Meier estimates of AF- free survival for a period of 1 year were comparable between both groups (log rank test, p = 0.606). Conclusion Cryoballoon is a feasible method for pulmonary vein isolation with similar success rates to radiofrequency ablation. Cryoballoon ablation is safe with shorter duration of the procedure.

Ostium

10.1093/qjmed/hcaa041.027

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Effect of ablation of adenosine induced pulmonary veins dormant conduction after pulmonary vein isolation (PVI) on intermediate term recurrence of atrial fibrillation (AF)

QJM (2018)

S Abdelhafeez Khaled Mazen Tawfik Ibrahim A M Abdelmoteleb Haitham Badran Lamyaa Allam

Isolation

10.1093/qjmed/hcy200.025

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Left atrium in cardiac resynchronization therapy: Active participant or innocent bystander

Journal of the Saudi Heart Association (2017)

Haitham Badran M A Abdelhamid Mazen Tawfik Ibrahim A M Abdelmoteleb John Kamel Zarif

Cardiac resynchronization therapy (CRT) is an established treatment for patients with advanced heart failure that results in improvement of left ventricle (LV) systolic function and LV reverse remodeling. This may have a positive effect on the size and the function of the left atrium (LA). We assessed the LA function, dimensions, and volumes before and after CRT implantation.A total of 37 patients with mean age of 55.3 ± 9.64 years including 11 (29.7%) females, having symptomatic heart failure [ejection fraction (EF) <35%, left bundle branch block >120 ms, with New York Heart Association III or ambulatory class IV] were enrolled, and underwent CRT implantation. M-mode, two-dimensional (2D) echocardiography, tissue Doppler imaging, and 2D strain (ɛ) imaging were done assessing LV volumes, ejection fraction, and diastolic function, LA diameter, area, maximal and minimal volumes, LA EF, and longitudinal strain (ɛ). Patients were reassessed after 3 months. A reduction in LV end-systolic volume of ≥10% was defined as volumetric responders to CRT. Patients with decompensated New York Heart Association class IV, sustained atrial arrhythmias, rheumatic or congenital heart diseases, nonleft bundle branch block, and those who were poorly echogenic, were excluded.Twenty-four (64.8%) patients were volumetric responders (group A). Both groups were matched regarding demographic, clinical, electrocardiographic, and echocardiographic criteria apart from the LA dimension and volumes which were significantly lower in the responders group prior to CRT. At the end of the follow-up, only the responders group had further significant reduction in LA diameter (41.6 ± 1.67 vs. 43.88 ± 1.82 mm, p < 0.01), maximal volume (62.2 ± 18.3 vs. 73.04 ± 21.78 ml, p < 0.01), minimal volume (32.6 ± 12.3 vs. 41.8 ± 13.97, p < 0.01), together with a significant increase in LA EF (48.3 ± 11.3 vs. 41.99 ± 13.9, p < 0.01), positive longitudinal strain (16.59% ± 5.89 vs. 12.45% ± 6.12, p < 0.01), and negative longitudinal strain (-3.3 ± 1.9 vs. -1.62 ± 1.2, p < 0.01) compared to baseline readings, a finding that was not present in the nonresponders group. In addition, atrial fibrillation was significantly higher in the nonresponders group. Baseline LA diameter and volumes were found to be independent predictors of response to CRT by multivariate analysis.CRT induces LA anatomic, electrical, and structural reverse remodeling that could be assessed by conventional 2D echocardiography and 2D (ɛ) strain imaging. LA dimension and volumes were independent predictors of response to CRT and can help in selection of candidates for it.

10.1016/j.jsha.2017.01.008

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