Introduction: Heart failure with preserved ejection fraction (HFpEF) is a common comorbidity in atrial fibrillation (AF) patients and contributes to AF progression and stroke risk. Hypothesis: We explore the hemodynamic effects of left atrial pressure (LAP), which was directly measured during AF catheter ablation (AFCA), on HFpEF based on the H 2 FPEF score. Methods: We included 1,426 patients (73.3% male, median age, 61.0 [54.0-68.0] years; 45.7% persistent AF) who underwent AFCA, LAP measurements at both AF and sinus rhythm (SR), echocardiogram, and H 2 FPEF score, and excluded the patients with EF <50%. We divided patients into low-risk (< 6 points) and high-risk ( ≥ 6 points) HFpEF groups and measured LAP-mean depending on heart rates 90, 100, 110, and 120 bpm during right atrial pacing (Pace-HR) and isoproterenol (ISO-HR) infusion in all patients. Results: The LAP-mean was sequentially and significantly higher according to the H 2 FPEF score (p<0.001) and had an independent association with the high-risk HFpEF group (OR 1.37 per 10mmHg increase [1.13-1.67], p=0.001). LAP-mean increased significantly with increasing Pace-HR (90-120 bpm, 10.4 to 11.6 mmHg, p<0.001) but decreased with ISO-HR (90-120 bpm, 10.2 to 8.1 mmHg, p<0.001). In patients with paroxysmal AF, LAP-mean[AF] was significantly higher than LAP-mean[SR] (p<0.001), but not in those with non-paroxysmal AF (p=0.557). In patients with paroxysmal AF, ΔLAP-mean[Pace-HR, 120-90bpm] was significantly higher than that of non-paroxysmal AF (p<0.001). Conclusions: LAP is independently associated with H 2 FPEF score and has inverse rate-dependent response depending on pacing or ISO infusion. Higher increase of LAP during AF or higher Pace-HR contributes to more severe symptoms in patients with paroxysmal AF than in non-paroxysmal AF.
Abstract Introduction CHA₂DS₂-VASc score (CVS) is widely used to estimate the risk of stroke in atrial fibrillation (AF) patients. However, CVS does not include genetic risk, and the risk model for stroke dose not well developed after AF catheter ablation (AFCA). We explored the clinical and genetic risks for ischemic stroke (IS) and compared the difference in prediction power according to ethnicity. Methods We used available genome-wide association study (GWAS) data in European (34217 IS, 406111 controls) and Asian (22664 IS, 152022 controls) to develop polygenic risk score (PRS) for IS in 2897 independent Korean AF patients (Median 60 [IQR 52, 67] years, male 74.0%, paroxysmal AF 66.3%, anticoagulation rate 60% in 1367 patients over 2 points of CVS) who underwent the AFCA. The patients with IS within 2 weeks after the AFCA were excluded. In the independent AF cohort during the median 50 [IQR 28-94] months follow-up, 48 experienced the IS after the AFCA. We developed two different PRS derived from European and Asian GWAS data and then two different CVS-combined PRS models in the independent cohort. After including SNPs with p-value <5e-8 in the development cohort, rs635634 and rs671 were used in the CVS-combined European PRS (CVS-EPRS) and CVS-combined Asian PRS (CVS-APRS) model, respectively in the independent cohort. We compared the C index of risk models to investigate the prediction power for the IS. Results The CVS was significantly higher in the patients with IS than in their counterparts (3.0 IQR [1.0, 4.0 vs. 1.0 [1.0, 2.0], p<0.001). The overall C index was 0.716 in CVS alone model, 0.711 in the CVS-EPRS model, and 0.725 CVS-APRS model. For predicting 1-year IS after the AFCA, the CVS-APRS model improved the C index as compared to CVS alone model (0.834 vs. 0.813, p=0.037). For predicting 3-year IS after the AFCA, the C-index was higher in the CVS-APRS model as compared to the CVS-EPRS model (0.746 vs. 0.721, p=0.030) Conclusions In AF patients with the AFCA, genetic polymorphism with clinical risk factors contributed to predict the 1-year IS. However, ethnicity might be an important factor in adapting genetic contributions to predicting IS.Study flow chartTime dependent ROC curve
Abstract Funding Acknowledgements Type of funding sources: None. Background There is a genetic background in pulmonary vein (PV) development and atrial fibrillation (AF). However, the genetic trait of PV variations and their rhythm outcome after AF catheter ablation (AFCA) is unclear. Objective We explored the genetic and clinical characteristics and long-term rhythm outcomes of AF patients with PV variation or left common trunkus (LCT)-PV. Methods We included 2,897 AF patients (74.0% male, age 59.0 ± 10.7 years, 66.3% paroxysmal AF) with available genome-wide association study results, cardiac computed tomogram data, and protocol-based regular rhythm follow-up from the Yonsei AF ablation cohort database. We defined LCT-PV when the upper and lower PV separate at >10 mm distal to the left PV antrum margin. PV variations included both LCT-PV and accessory PVs. We analyzed the polygenic risk score (PRS) of 12 AF-associated genes (DSP, GJA1, HCN4, KCNQ1, NPPA, PITX2, RYR2, SCN5a, SHOX2, ATP2A2, TBX3, and TBX5) and long-term rhythm outcomes after AFCA. Results We found PV variation in 296 (10.2%) and LCT-PV in 102 (3.5%). PRS of 1,227 single nucleotid polymorphisms (SNPs) was significantly higher in PV variation patients (p=4.93e-08) and LCT-PV patients (p=1.95e-20). The patients with LCT-PV had higher CHA2DS2VASc scores (p=0.024) and lower atrial epicardial adipose tissue volume (p=0.034). During 39.7 ± 34.8 months follow-up period, LCT-PV patients had a significantly higher recurrence rate than their counter part in the paroxysmal AF sub-group (Log-rank p=0.036), but not in overall PV variations. LCT-PV with the highest 10% PRS was independently associated with AF recurrence after AFCA (HR 2.10, 95% CI 1.21-3.63, p=0.008). Conclusions Among the patients who underwent AFCA, PV variation, including LCT-PV, has a significant genetic background. The post-AFCA recurrence rate was significantly higher in patients with LCT-PV and high PRS, especially in paroxysmal AF.
Abstract Funding Acknowledgements Type of funding sources: None. Purpose We compared the efficacy, safety, and heart rate variability (HRV) after cryo-balloon (Cryo-PVI), high-power short-duration (HPSD-PVI) or conventional radiofrequency pulmonary vein isolation (conventional-PVI) in patients with atrial fibrillation (AF). Methods In this retrospective analysis of single-center cohort, we included 2,975 patients who underwent AF catheter ablation (74.1% male, median 60 years old, 74.1% paroxysmal AF). We compared the procedural factors, rhythm outcomes, complication rates, and post-procedural heart rate variability (HRV) between the Cryo-PVI (n=493), HPSD-PVI (n=638), and conventional-PVI (n=1,844). Results In spite of significantly shorter procedural time in the Cryo-PVI group (73 min for Cryo-PVI vs 110 min for HPSD-PVI vs 153 min for conventional-PVI, p<0.001), major complication (2.8% for Cryo-PVI vs 2.4% for HPSD-PVI vs 2.5% for conventional-PVI, p=0.875) or freedom from late recurrence (log-rank, p=0.357) did not differ among the three ablation groups. Cryo-PVI showed significantly lower risk for AF recurrence in patients with paroxysmal AF (weighted hazard ratio [WHR] 0.62, 95% confidence interval [CI] 0.41-0.93), but worse rhythm outcome in those with non-paroxysmal AF (WHR 1.47, 95% CI 1.06-2.05, p for interaction=0.002) as compared with conventional-PVI. In the subgroup analysis for HRV (n=1,429), Cryo-PVI group showed significantly higher low-frequency to high-frequency ratio at post-procedure 3 month (p<0.001), 1-year (p<0.001), and 2-year (p=0.023). Conclusion Cryo-PVI showed better rhythm outcome in patients with paroxysmal AF, but worse outcome in those with non-paroxysmal AF with higher long-term post-procedural sympathetic nervous activity as compared with conventional-PVI.
Abstract Background Although active rhythm control by atrial fibrillation (AF) catheter ablation (AFCA) reduces left atrial (LA) dimension, blunted atrial reverse remodeling can be observed in patients with significant atrial myopathy. We explored the characteristics and long-term outcomes of AF patients who showed blunted atrial reverse remodeling despite no AF recurrence within a year after AFCA. Methods Among a total of 2,756 patients with AFCA, we included 1,685 patients (74.8% male, 60.2±10.1 years old, 54.5% paroxysmal AF) who underwent both baseline and 1-year follow-up echocardiogram, baseline LA>40mm, and did not recur within a year. We divided them into tertile groups (T1–T3) based on one-year percent change of LA dimension after propensity matching for age, sex, AF type, and baseline LA dimension. We also investigated the patients' genetic characteristics with blunted LA reverse remodeling (T1) using a genome-wide association study (GWAS). Results Patients with blunted LA reverse remodeling (T1, n=424) were independently associated with body mass index (OR 1.082 [1.010–1.160], p=0.025), LA peak pressure (OR 1.010 [1.002–1.019], p=0.019), LA wall thickness (OR 0.448 [0.252–0.789], p=0.006), LA voltage (OR 0.651 [0.463–0.907], p=0.012), and pericardial fat volume (OR 1.004 [1.001–1.008], p=0.014). Throughout 65.9±37.4 months of follow-up, the incidence of AF recurrence a year after the procedure was significantly higher in the T1 group than in T2 or T3 groups (Log-rank p<0.001). Among 894 patients with GWAS, ATXN1, XPO7, KRR1_PHLDA1, ZFHX3, and their polygenic risk score were associated with blunted LA reverse remodeling. Conclusions Patients with blunted LA reverse remodeling after AFCA were independently associated with low LA voltage, thin wall thickness, high LA pressure, and fat volume, and have a genetic background. Long-term clinical recurrence a year after AFCA was higher in this patient group with suspicious atrial myopathy. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health and WelfareNational Research Foundation of Korea
Introduction: Recently, delaying atrial fibrillation (AF) catheter ablation (AFCA) by 12 months for antiarrhythmic drug (AAD) management didn't result in reduced ablation efficacy. In this study, we explored AFCA rhythm outcomes based on the diagnosis-to-ablation time (DAT) in AAD-resistant persistent AF (PeAF). Methods: We included 1,038 AAD-resistant PeAF patients with clear DAT (male 79.8%, 61.0 [54.0-68.0]) who underwent AFCA followed by guidelines-based regular rhythm follow-up. Before AFCA, all patients underwent optimal medial therapy (AAD) with or without cardioversion. Patients on AADs, who experienced paroxysmal type recurrence, were classified as AAD-partial-responders, while those maintaining PeAF were categorized as AAD-non-responders. We determined the DAT cut-off for rhythm outcome using a maximum likelihood approach in a Cox regression model. Results: AAD-partial-responders showed higher body mass index (p=0.007), larger left atrial diameter (p<0.001), lower eGFR (p=0.039). AAD non-responder showed higher recurrence after AFCA (Log-rank p<0.001; aHR 1.75, 95% CI 1.33-2.30, p<0.001). The maximum likelihood estimation from Cox analysis showed bimodal peaks at 22 and 40 months. In contrast, DAT 12 months didn't show discrimination power for post-AFCA recurrence (Log-rank p=0.290, HR1.13[0.91-1.41], p=0.281), while DAT>22 months (Log-rank p=0.001, HR1.34[1.09-1.64], p=0.005) and DAT>40 months (Log-rank p=0.001, HR1.34[1.09-1.64], p=0.006) significantly indicated poor rhythm outcome. DAT>22 months among AAD-partial-responders (Log-rank p=0.012, HR 1.96 [1.16-3.31], p=0.012) and DAT>40 months among AAD-non-responders (Log-rank p=0.009, HR 1.28 [1.02-1.60], p=0.031) were a poor prognostic factor for rhythm control after AFCA. Conclusions: DAT and AAD responsiveness affected the rhythm outcome of AFCA. Delaying AFCA over 22 months of DAT is not desirable in PeAF patients even under optimal medical therapy with AADs.
Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health and Welfare the Basic Science Research Program run by the National Research Foundation of Korea (NRF). Background Atrial fibrillation (AF) is a chronic progressive disease that recurs continuously even after successful AF catheter ablation (AFCA). Objective We explored the mechanism of this long-term recurrence by comparing the patient characteristics and redo-ablation findings. Methods Among 4,248 patients who underwent a de novo AFCA and protocol-based rhythm follow-up at single centers, we enrolled 1,417 patients (71.7% male, age 60.0 [52.0–67.0] years, 57.9% paroxysmal AF) who experienced clinical recurrences (CRs) of the disease, and divided them according to the period of recurrence: within one year (n=645), 1–2 years (n=339), 2–5 years (n=308), and after 5-years (CR>5yr, n=125). We also compared the redo-mapping and ablation outcomes in 198 patients. Results In patients with a CR>5yr, the proportion of paroxysmal AF was higher (p=0.031); however, the left atrial (LA) volume (computed tomography, p=0.003), LA voltage (p=0.003), frequency of early recurrence (p<0.001), and use of post-procedure anti-arrhythmic drugs (p<0.001) were lower. A CR>5yr was independently associated with the low LA volume (odds ratio [OR] 0.99 [0.99–1.00], p=0.019), low LA voltage (OR 0.62 [0.41–0.95], p=0.030), and lower early recurrence (OR 0.39 [0.23–0.64], p<0.001). Extra-pulmonary vein (PV) triggers (P for trend 0.003) during repeat procedures were significantly greater in patients with a CR>5yr, despite no difference in the de novo protocol. The rhythm outcome of repeat ablation procedures did not differ with the timing of the CR (log-rank p=0.330). Conclusions Patients with a later CR showed a smaller LA volume, lower LA voltage, and higher extra-PV triggers during the repeat procedure, suggesting progression of AF.
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