Pub Date : 2024-10-01DOI: 10.1016/j.jacep.2024.05.032
Background
Electrical storm (ES) is a life-threatening condition, associated with substantial early and subacute mortality. Catheter ablation (CA) is a well-established therapy for ES. However, data regarding the impact of CA on the short-term and midterm survival of patients admitted for ES remain unclear.
Objectives
This multicenter study aimed to investigate the impact of CA of ES on survival outcomes, while accounting for key patient characteristics associated with treatment selection.
Methods
A propensity score–matching (PSM) analysis was performed on 780 consecutive patients admitted for ES in 4 tertiary centers. PSM (1:1) based on the main characteristics associated with the use of CA or medical therapy alone was performed, resulting in 2 groups of 288 patients.
Results
After PSM, patients who underwent CA (n = 288) and those treated with medical therapy alone (n = 288) did not present any significant differences in the main demographic characteristics, ES presentation, and management. Compared with medical therapy alone, CA was associated with a significantly lower rate of ES recurrence at 1 year (5% vs 26%; P < 0.001). Similarly, CA was associated with a higher 1-year (91% vs 81%; P < 0.001) and 3-year (78% vs 71%; P = 0.017) survival after discharge. In subgroup analyses, effect of ablation therapy remained consistent in patients older than 70 years of age (HR: 0.39; 95% CI: 0.24-0.66), with substantial efficacy in patients with a LVEF <35% (HR: 0.39; 95% CI: 0.27-0.59).
Conclusions
In propensity-matched analyses, this large study shows that CA-based management of patients admitted for ES is associated with a reduction in mortality compared with medical treatment, particularly in patients with a low ejection fraction.
背景:电风暴(ES)是一种危及生命的疾病,与早期和亚急性期的高死亡率有关。导管消融术(CA)是治疗 ES 的一种行之有效的疗法。然而,有关导管消融对因 ES 而入院的患者短期和中期存活率影响的数据仍不清楚:这项多中心研究旨在调查 ES CA 对生存结果的影响,同时考虑与治疗选择相关的主要患者特征:方法:对4个三级中心连续收治的780名ES患者进行倾向评分匹配(PSM)分析。根据与使用 CA 或单纯药物治疗相关的主要特征进行倾向评分匹配(1:1),得出 2 组共 288 名患者:结果:经过PSM分析,接受CA治疗的患者(288人)和单纯接受药物治疗的患者(288人)在主要人口统计学特征、ES表现和治疗方法上没有明显差异。与单纯药物治疗相比,接受 CA 治疗的患者 1 年后 ES 复发率明显降低(5% vs 26%; P < 0.001)。同样,CA 与较高的出院后 1 年生存率(91% vs 81%;P < 0.001)和 3 年生存率(78% vs 71%;P = 0.017)相关。在亚组分析中,消融治疗对 70 岁以上患者的疗效保持一致(HR:0.39;95% CI:0.24-0.66),对 LVEF 结论的患者疗效显著:在倾向匹配分析中,这项大型研究表明,与药物治疗相比,对因 ES 入院的患者进行基于 CA 的治疗可降低死亡率,尤其是射血分数较低的患者。
{"title":"Impact of Catheter Ablation of Electrical Storm on Survival","authors":"","doi":"10.1016/j.jacep.2024.05.032","DOIUrl":"10.1016/j.jacep.2024.05.032","url":null,"abstract":"<div><h3>Background</h3><div>Electrical storm (ES) is a life-threatening condition, associated with substantial early and subacute mortality. Catheter ablation (CA) is a well-established therapy for ES. However, data regarding the impact of CA on the short-term and midterm survival of patients admitted for ES remain unclear.</div></div><div><h3>Objectives</h3><div>This multicenter study aimed to investigate the impact of CA of ES on survival outcomes, while accounting for key patient characteristics associated with treatment selection.</div></div><div><h3>Methods</h3><div>A propensity score–matching (PSM) analysis was performed on 780 consecutive patients admitted for ES in 4 tertiary centers. PSM (1:1) based on the main characteristics associated with the use of CA or medical therapy alone was performed, resulting in 2 groups of 288 patients.</div></div><div><h3>Results</h3><div>After PSM, patients who underwent CA (n = 288) and those treated with medical therapy alone (n = 288) did not present any significant differences in the main demographic characteristics, ES presentation, and management. Compared with medical therapy alone, CA was associated with a significantly lower rate of ES recurrence at 1 year (5% vs 26%; <em>P <</em> 0.001). Similarly, CA was associated with a higher 1-year (91% vs 81%; <em>P <</em> 0.001) and 3-year (78% vs 71%; <em>P =</em> 0.017) survival after discharge. In subgroup analyses, effect of ablation therapy remained consistent in patients older than 70 years of age (HR: 0.39; 95% CI: 0.24-0.66), with substantial efficacy in patients with a LVEF <35% (HR: 0.39; 95% CI: 0.27-0.59).</div></div><div><h3>Conclusions</h3><div>In propensity-matched analyses, this large study shows that CA-based management of patients admitted for ES is associated with a reduction in mortality compared with medical treatment, particularly in patients with a low ejection fraction.</div></div>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141874816","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01DOI: 10.1016/j.jacep.2024.06.019
Background
Although smoking heightens the risk of AF, it remains unknown if that risk is amenable to modification after smoking cessation.
Objectives
This study sought to evaluate the association between smoking cessation and atrial fibrillation (AF) risk in a large longitudinal cohort.
Methods
After excluding those with prevalent AF and no history of smoking at baseline, we evaluated 146,772 UK Biobank participants with serial smoking assessments. We compared AF risk between former smokers at baseline and those who quit smoking during the study to current smokers. Incident AF was ascertained from outpatient and inpatient encounters and identified using International Classification of Diseases codes. Cox models were used to compare the risk of incident AF among current and former smokers as well as those who quit smoking during the study while controlling for age, sex, race, body mass index, education, cardiovascular comorbidities, alcohol use, and pack-years.
Results
Among the 146,772 participants (48.3% female; age: 57.3 ± 7.9 years), 37,377 (25.5%) currently smoked; 105,429 (72.0%) were former smokers; and 3,966 (2.7%) quit smoking during the study. Over a mean 12.7 ± 2.0 years of follow-up, 11,214 (7.6%) participants developed AF. Compared to current smokers, the adjusted risk of AF was 13% lower in former smokers (HR: 0.87; 95% CI: 0.83-0.91) and 18% lower in those who quit smoking during the study (HR: 0.82; 95% CI: 0.70-0.95).
Conclusions
Compared to those who continue to smoke, smoking cessation was associated with a lower risk of AF.
{"title":"Smoking Cessation and Incident Atrial Fibrillation in a Longitudinal Cohort","authors":"","doi":"10.1016/j.jacep.2024.06.019","DOIUrl":"10.1016/j.jacep.2024.06.019","url":null,"abstract":"<div><h3>Background</h3><div>Although smoking heightens the risk of AF, it remains unknown if that risk is amenable to modification after smoking cessation.</div></div><div><h3>Objectives</h3><div>This study sought to evaluate the association between smoking cessation and atrial fibrillation (AF) risk in a large longitudinal cohort.</div></div><div><h3>Methods</h3><div>After excluding those with prevalent AF and no history of smoking at baseline, we evaluated 146,772 UK Biobank participants with serial smoking assessments. We compared AF risk between former smokers at baseline and those who quit smoking during the study to current smokers. Incident AF was ascertained from outpatient and inpatient encounters and identified using International Classification of Diseases codes. Cox models were used to compare the risk of incident AF among current and former smokers as well as those who quit smoking during the study while controlling for age, sex, race, body mass index, education, cardiovascular comorbidities, alcohol use, and pack-years.</div></div><div><h3>Results</h3><div>Among the 146,772 participants (48.3% female; age: 57.3 ± 7.9 years), 37,377 (25.5%) currently smoked; 105,429 (72.0%) were former smokers; and 3,966 (2.7%) quit smoking during the study. Over a mean 12.7 ± 2.0 years of follow-up, 11,214 (7.6%) participants developed AF. Compared to current smokers, the adjusted risk of AF was 13% lower in former smokers (HR: 0.87; 95% CI: 0.83-0.91) and 18% lower in those who quit smoking during the study (HR: 0.82; 95% CI: 0.70-0.95).</div></div><div><h3>Conclusions</h3><div>Compared to those who continue to smoke, smoking cessation was associated with a lower risk of AF.</div></div>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142262488","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01DOI: 10.1016/j.jacep.2024.05.008
Background
Genetic disease has recently emerged as a cause of cardiac conduction disorders (CCDs), but the diagnostic yield of genetic testing and the contribution of the different genes to CCD is still unsettled.
Objectives
This study sought to determine the diagnostic yield of genetic testing in young adults with CCD of unknown etiology requiring pacemaker implantation. We also studied the prevalence of rare protein-altering variants across individual genes and functional gene groups.
Methods
We performed whole exome sequencing in 150 patients with CCD of unknown etiology who had permanent pacemaker implanted at age ≤60 years at 14 Spanish hospitals. Prevalence of rare protein-altering variants in patients with CCD was compared with a reference population of 115,522 individuals from gnomAD database (control subjects).
Results
Among 39 prioritized genes, patients with CCD had more rare protein-altering variants than control subjects (OR: 2.39; 95% CI: 1.75-3.33). Significant enrichment of rare variants in patients with CCD was observed in all functional gene groups except in the desmosomal genes group. Rare variants in the nuclear envelope genes group exhibited the strongest association with CCD (OR: 6.77; 95% CI: 3.71-13.87). Of note, rare variants in sarcomeric genes were also enriched (OR: 1.73; 95% CI: 1.05-3.10). An actionable genetic variant was detected in 21 patients (14%), with LMNA being the most frequently involved gene (4.6%).
Conclusions
Unrecognized rare genetic variants increase the risk of CCD in young adults with CCD of unknown etiology. Genetic testing should be performed in patients age ≤60 years with CCD of unknown etiology. The role of genetic variants in sarcomeric genes as a cause of CCD should be further investigated.
{"title":"Rare Genetic Variants in Young Adults Requiring Pacemaker Implantation","authors":"","doi":"10.1016/j.jacep.2024.05.008","DOIUrl":"10.1016/j.jacep.2024.05.008","url":null,"abstract":"<div><h3>Background</h3><div>Genetic disease has recently emerged as a cause of cardiac conduction disorders (CCDs), but the diagnostic yield of genetic testing and the contribution of the different genes to CCD is still unsettled.</div></div><div><h3>Objectives</h3><div>This study sought to determine the diagnostic yield of genetic testing in young adults with CCD of unknown etiology requiring pacemaker implantation. We also studied the prevalence of rare protein-altering variants across individual genes and functional gene groups.</div></div><div><h3>Methods</h3><div>We performed whole exome sequencing in 150 patients with CCD of unknown etiology who had permanent pacemaker implanted at age ≤60 years at 14 Spanish hospitals. Prevalence of rare protein-altering variants in patients with CCD was compared with a reference population of 115,522 individuals from gnomAD database (control subjects).</div></div><div><h3>Results</h3><div>Among 39 prioritized genes, patients with CCD had more rare protein-altering variants than control subjects (OR: 2.39; 95% CI: 1.75-3.33). Significant enrichment of rare variants in patients with CCD was observed in all functional gene groups except in the desmosomal genes group. Rare variants in the nuclear envelope genes group exhibited the strongest association with CCD (OR: 6.77; 95% CI: 3.71-13.87). Of note, rare variants in sarcomeric genes were also enriched (OR: 1.73; 95% CI: 1.05-3.10). An actionable genetic variant was detected in 21 patients (14%), with <em>LMNA</em> being the most frequently involved gene (4.6%).</div></div><div><h3>Conclusions</h3><div>Unrecognized rare genetic variants increase the risk of CCD in young adults with CCD of unknown etiology. Genetic testing should be performed in patients age ≤60 years with CCD of unknown etiology. The role of genetic variants in sarcomeric genes as a cause of CCD should be further investigated.</div></div>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141603650","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01DOI: 10.1016/j.jacep.2024.06.024
{"title":"Left Bundle Branch Area Pacing for LBBB","authors":"","doi":"10.1016/j.jacep.2024.06.024","DOIUrl":"10.1016/j.jacep.2024.06.024","url":null,"abstract":"","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142035801","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01DOI: 10.1016/j.jacep.2024.08.003
Catheter ablation is a well-established and effective strategy for the management of ventricular tachycardia (VT). However, the identification and characterization of arrhythmogenic substrates for targeted ablation remain challenging. Electrogram abnormalities and responses to pacing during VT provide the classical and most validated methods to identify substrates. However, the 3-dimensional nature of the myocardium, nonconductive tissue, and heterogeneous strands of conductive tissue at the border zones or through the nonconductive zones can prohibit easy electrical sampling and identification of the tissue critical to VT. Intracardiac echocardiography is critical for identification of anatomy, examination of catheter approach and contact, assessment of tissue changes during ablation, and even potential substrates as echogenic regions, but lacks specificity with regard to the latter compared with advanced modalities. In recent decades, cardiac magnetic resonance, computed tomography and positron emission tomography have emerged as valuable tools in the periprocedural evaluation of VT ablation. Cardiac magnetic resonance has unparalleled soft tissue and temporal resolution and excels at identification of expanded interstitial space caused by myocardial infarction, fibrosis, inflammation, or infiltrative myopathies. Computed tomography has excellent spatial resolution and is optimal for identification of anatomic variabilities including wall thickness, thrombus, and lipomatous metaplasia. Positron emission tomography excels at identification of substrates including amyloidosis, sarcoidosis, and other inflammatory substrates. These imaging modalities are vital for assessing arrhythmogenic substrates, guiding optimal access strategy, and assessing ablation efficacy. Although clearly beneficial in specific settings, further clinical trials are needed to enhance generalizability and optimize integration of cardiac imaging for VT ablation.
{"title":"Imaging to Facilitate Ventricular Tachycardia Ablation","authors":"","doi":"10.1016/j.jacep.2024.08.003","DOIUrl":"10.1016/j.jacep.2024.08.003","url":null,"abstract":"<div><div>Catheter ablation is a well-established and effective strategy for the management of ventricular tachycardia (VT). However, the identification and characterization of arrhythmogenic substrates for targeted ablation remain challenging. Electrogram abnormalities and responses to pacing during VT provide the classical and most validated methods to identify substrates. However, the 3-dimensional nature of the myocardium, nonconductive tissue, and heterogeneous strands of conductive tissue at the border zones or through the nonconductive zones can prohibit easy electrical sampling and identification of the tissue critical to VT. Intracardiac echocardiography is critical for identification of anatomy, examination of catheter approach and contact, assessment of tissue changes during ablation, and even potential substrates as echogenic regions, but lacks specificity with regard to the latter compared with advanced modalities. In recent decades, cardiac magnetic resonance, computed tomography and positron emission tomography have emerged as valuable tools in the periprocedural evaluation of VT ablation. Cardiac magnetic resonance has unparalleled soft tissue and temporal resolution and excels at identification of expanded interstitial space caused by myocardial infarction, fibrosis, inflammation, or infiltrative myopathies. Computed tomography has excellent spatial resolution and is optimal for identification of anatomic variabilities including wall thickness, thrombus, and lipomatous metaplasia. Positron emission tomography excels at identification of substrates including amyloidosis, sarcoidosis, and other inflammatory substrates. These imaging modalities are vital for assessing arrhythmogenic substrates, guiding optimal access strategy, and assessing ablation efficacy. Although clearly beneficial in specific settings, further clinical trials are needed to enhance generalizability and optimize integration of cardiac imaging for VT ablation.</div></div>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142371852","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-29DOI: 10.1016/j.jacep.2024.09.017
Jonathan P Ariyaratnam, Melissa E Middeldorp, Anthony G Brooks, Gijo Thomas, Kadhim Kadhim, Rajiv Mahajan, Rajeev K Pathak, Glenn D Young, Jonathan M Kalman, Prashanthan Sanders
Background: The coronary sinus is an arrhythmogenic structure that can initiate and maintain atrial fibrillation (AF). Coronary sinus ablation has been shown to be effective in prolonging the AF cycle length and terminating AF in patients with both paroxysmal and persistent AF who have persistent AF after pulmonary vein isolation (PVI).
Objectives: The objective of this study was to undertake a randomized controlled trial to investigate the efficacy of coronary sinus isolation (CSI) as an adjunctive ablation strategy for the treatment of high-burden AF.
Methods: Consecutive patients presenting with symptomatic long episodes of paroxysmal AF (≥48 h but ≤7 days) or persistent AF (>7 days and ≤12 months) referred for first-time ablation were enrolled. Participants were randomized to either PVI, roofline ablation, and CSI (CSI group) or PVI and roofline ablation only (non-CSI group). Participants were assessed postprocedurally via clinical follow-up and 7-day Holter monitoring at regular intervals. The primary outcome was single-procedure drug-free atrial arrhythmia-free survival at 2 years.
Results: One hundred participants were recruited to the study; 48 were randomized to the CSI group and 52 to the non-CSI group. Acutely successful CSI was achieved in 45 of the 48 patients in the CSI group. At 2 years follow up, 30 of 48 patients (62.5%) in the CSI group and 33 of 52 (63.4%) in the non-CSI group were free from arrhythmia recurrence. Single-procedure drug-free survival at 2 years was no different between groups (P = 0.91). Similarly, multiple procedure drug assisted survival at 5 years was not different between groups (P = 0.80). Complication rates were not significantly different between groups (P = 0.19).
Conclusions: Adjunctive CSI as part of a de novo ablation strategy does not confer any additional benefit greater than PVI and roofline for the treatment of high-burden AF.
{"title":"Coronary Sinus Isolation for High-Burden Atrial Fibrillation: A Randomized Clinical Trial.","authors":"Jonathan P Ariyaratnam, Melissa E Middeldorp, Anthony G Brooks, Gijo Thomas, Kadhim Kadhim, Rajiv Mahajan, Rajeev K Pathak, Glenn D Young, Jonathan M Kalman, Prashanthan Sanders","doi":"10.1016/j.jacep.2024.09.017","DOIUrl":"10.1016/j.jacep.2024.09.017","url":null,"abstract":"<p><strong>Background: </strong>The coronary sinus is an arrhythmogenic structure that can initiate and maintain atrial fibrillation (AF). Coronary sinus ablation has been shown to be effective in prolonging the AF cycle length and terminating AF in patients with both paroxysmal and persistent AF who have persistent AF after pulmonary vein isolation (PVI).</p><p><strong>Objectives: </strong>The objective of this study was to undertake a randomized controlled trial to investigate the efficacy of coronary sinus isolation (CSI) as an adjunctive ablation strategy for the treatment of high-burden AF.</p><p><strong>Methods: </strong>Consecutive patients presenting with symptomatic long episodes of paroxysmal AF (≥48 h but ≤7 days) or persistent AF (>7 days and ≤12 months) referred for first-time ablation were enrolled. Participants were randomized to either PVI, roofline ablation, and CSI (CSI group) or PVI and roofline ablation only (non-CSI group). Participants were assessed postprocedurally via clinical follow-up and 7-day Holter monitoring at regular intervals. The primary outcome was single-procedure drug-free atrial arrhythmia-free survival at 2 years.</p><p><strong>Results: </strong>One hundred participants were recruited to the study; 48 were randomized to the CSI group and 52 to the non-CSI group. Acutely successful CSI was achieved in 45 of the 48 patients in the CSI group. At 2 years follow up, 30 of 48 patients (62.5%) in the CSI group and 33 of 52 (63.4%) in the non-CSI group were free from arrhythmia recurrence. Single-procedure drug-free survival at 2 years was no different between groups (P = 0.91). Similarly, multiple procedure drug assisted survival at 5 years was not different between groups (P = 0.80). Complication rates were not significantly different between groups (P = 0.19).</p><p><strong>Conclusions: </strong>Adjunctive CSI as part of a de novo ablation strategy does not confer any additional benefit greater than PVI and roofline for the treatment of high-burden AF.</p>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-09-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142465587","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-27DOI: 10.1016/j.jacep.2024.09.018
Rose Crowley, David Chieng, Louise Segan, Jeremy William, Hariharan Sugumar, Sandeep Prabhu, Aleksandr Voskoboinik, Liang-Han Ling, Joseph B Morton, Geoffrey Lee, Alex J McLellan, Michael Wong, Rajeev K Pathak, Laurence Sterns, Matthew Ginks, Prashanthan Sanders, Peter M Kistler, Jonathan M Kalman
Background: Many patients with persistent atrial fibrillation (PsAF) have progressed from an initial paroxysmal phenotype; however, there are patients in whom atrial fibrillation (AF) is persistent at diagnosis. Relatively little is known about this subgroup, but prior observational studies have suggested these patients have worse outcomes with ablation.
Objectives: This study sought to: 1) assess demographic and electrophysiologic characteristics of patients with PsAF at first diagnosis compared with those with who have progressed from paroxysmal atrial fibrillation (PAF); and 2) assess the impact of pattern of AF at diagnosis on recurrence post ablation.
Methods: CAPLA (Catheter Ablation for persistent atrial fibrillation: A Multicentre randomised trial of Pulmonary vein isolation [PVI] vs PVI with posterior Left Atrial wall isolation [PWI]) was a multicenter trial that randomized patients with PsAF to PVI plus PWI or PVI alone. Follow-up was 12 months. Outcomes were assessed after a 3-month blanking period.
Results: A total of 334 patients were included (median age 65.6 years, 23.1% female), 194 (58.1%) had PsAF at first AF diagnosis and 140 (41.9%) had PAF. Patients with PsAF at diagnosis were younger (age 64.0 vs 67.7 years, P = 0.005), had higher rates of heart failure (P < 0.001), and lower left ventricular ejection fraction (54.5% IQR: 40-60 vs 60% IQR: 50-61, P = 0.007). AF recurrence occurred in 85 (43.8%) with PsAF at diagnosis and 70 (50%) with PAF at diagnosis. PsAF at diagnosis was not associated with risk of recurrence on univariable (HR: 0.802; 95% CI: 0.585-1.101; P = 0.173) or multivariable analysis (HR: 0.922; 95% CI: 0.647-1.312; P = 0.650). Median AF burden was 0% in both groups (P = 0.125). There was no difference in left atrial size (P = 0.337) or bipolar voltage (P = 0.579) between the groups.
Conclusions: In the CAPLA cohort of patients, pattern of AF at first diagnosis did not influence post-ablation rate of AF recurrence or AF burden. (Catheter Ablation for persistent atrial fibrillation: A Multicentre randomised trial of Pulmonary vein isolation [PVI] vs PVI with posterior Left Atrial wall isolation [PWI]; ACTRN12616001436460).
{"title":"Persistent Atrial Fibrillation Phenotypes and Ablation Outcomes: Persistent From Outset vs Progression From Paroxysmal AF.","authors":"Rose Crowley, David Chieng, Louise Segan, Jeremy William, Hariharan Sugumar, Sandeep Prabhu, Aleksandr Voskoboinik, Liang-Han Ling, Joseph B Morton, Geoffrey Lee, Alex J McLellan, Michael Wong, Rajeev K Pathak, Laurence Sterns, Matthew Ginks, Prashanthan Sanders, Peter M Kistler, Jonathan M Kalman","doi":"10.1016/j.jacep.2024.09.018","DOIUrl":"https://doi.org/10.1016/j.jacep.2024.09.018","url":null,"abstract":"<p><strong>Background: </strong>Many patients with persistent atrial fibrillation (PsAF) have progressed from an initial paroxysmal phenotype; however, there are patients in whom atrial fibrillation (AF) is persistent at diagnosis. Relatively little is known about this subgroup, but prior observational studies have suggested these patients have worse outcomes with ablation.</p><p><strong>Objectives: </strong>This study sought to: 1) assess demographic and electrophysiologic characteristics of patients with PsAF at first diagnosis compared with those with who have progressed from paroxysmal atrial fibrillation (PAF); and 2) assess the impact of pattern of AF at diagnosis on recurrence post ablation.</p><p><strong>Methods: </strong>CAPLA (Catheter Ablation for persistent atrial fibrillation: A Multicentre randomised trial of Pulmonary vein isolation [PVI] vs PVI with posterior Left Atrial wall isolation [PWI]) was a multicenter trial that randomized patients with PsAF to PVI plus PWI or PVI alone. Follow-up was 12 months. Outcomes were assessed after a 3-month blanking period.</p><p><strong>Results: </strong>A total of 334 patients were included (median age 65.6 years, 23.1% female), 194 (58.1%) had PsAF at first AF diagnosis and 140 (41.9%) had PAF. Patients with PsAF at diagnosis were younger (age 64.0 vs 67.7 years, P = 0.005), had higher rates of heart failure (P < 0.001), and lower left ventricular ejection fraction (54.5% IQR: 40-60 vs 60% IQR: 50-61, P = 0.007). AF recurrence occurred in 85 (43.8%) with PsAF at diagnosis and 70 (50%) with PAF at diagnosis. PsAF at diagnosis was not associated with risk of recurrence on univariable (HR: 0.802; 95% CI: 0.585-1.101; P = 0.173) or multivariable analysis (HR: 0.922; 95% CI: 0.647-1.312; P = 0.650). Median AF burden was 0% in both groups (P = 0.125). There was no difference in left atrial size (P = 0.337) or bipolar voltage (P = 0.579) between the groups.</p><p><strong>Conclusions: </strong>In the CAPLA cohort of patients, pattern of AF at first diagnosis did not influence post-ablation rate of AF recurrence or AF burden. (Catheter Ablation for persistent atrial fibrillation: A Multicentre randomised trial of Pulmonary vein isolation [PVI] vs PVI with posterior Left Atrial wall isolation [PWI]; ACTRN12616001436460).</p>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-09-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142500588","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-27DOI: 10.1016/j.jacep.2024.07.029
Zain M Virk, Majd A El-Harasis, Zachary T Yoneda, Katherine C Anderson, Lili Sun, Joseph A Quintana, Brittany S Murphy, James L Laws, Giovanni E Davogustto, Matthew J O'Neill, Bibin T Varghese, Diane M Crawford, Hollie L Williams, Mahsima Shabani, Cassady J Pelphrey, Dakota D Grauherr, Kelsey Tomasek, Yan Ru Su, Megan C Lancaster, Quinn S Wells, Jeffrey M Dendy, Pablo Saavedra, Juan C Estrada, Travis D Richardson, Sharon T Shen, Arvindh N Kanagasundram, Jay A Montgomery, Christopher R Ellis, George H Crossley, Harikrishna Tandri, Prince J Kannankeril, Steven A Lubitz, William G Stevenson, Fei Ye, Patrick T Ellinor, Lynne W Stevenson, Dan M Roden, M Benjamin Shoemaker
Background: TTN encodes a sarcomeric protein called titin. Pathogenic rare variants in TTN are the most common finding in patients with atrial fibrillation (AF) and positive genetic testing.
Objectives: This study sought to define the characteristics and outcomes in patients with AF and pathogenic TTN variants compared with genotype-negative patients with AF.
Methods: Patients who presented initially with AF were enrolled in an AF registry. Retrospectively they underwent research sequencing for cardiomyopathy and arrhythmia genes. TTN(+) AF cases were defined as participants with pathogenic or likely pathogenic (P/LP) rare variants located in exons with high cardiac expression. They were matched 1:2 with control subjects with no P/LP variants. Phenotyping used retrospective manual chart review.
Results: Among 2794 participants; 57 (2.0%) TTN(+) AF cases were identified and matched with 114 control subjects. Low QRS complex voltage was present more often in TTN(+) AF cases (18% vs 5%; P < 0.01), with no difference in PR, QRS interval, or QTc. More TTN(+) AF cases had persistent AF at enrollment (44% vs 30%; P = 0.028) and had undergone multiple cardioversions (61% vs. 37%; P < 0.01). By end of follow-up (median 8.3 years; Q1, Q3: 4.5, 13.7 years), 11% of TTN(+) AF cases developed sustained ventricular tachycardia/ventricular fibrillation, 44% left ventricular (LV) systolic dysfunction (LV ejection fraction <50%), and 47% met a combined endpoint of sustained ventricular tachycardia/ventricular fibrillation or LV systolic dysfunction.
Conclusions: TTN(+) AF patients undergo more cardioversions and have more persistent forms of AF. Approximately 50% develop LV systolic dysfunction and/or malignant ventricular arrhythmias. These results highlight the need for diagnostic evaluation and management in TTN(+) patients beyond the usual care for AF.
{"title":"Clinical Characteristics and Outcomes in Patients With Atrial Fibrillation and Pathogenic TTN Variants.","authors":"Zain M Virk, Majd A El-Harasis, Zachary T Yoneda, Katherine C Anderson, Lili Sun, Joseph A Quintana, Brittany S Murphy, James L Laws, Giovanni E Davogustto, Matthew J O'Neill, Bibin T Varghese, Diane M Crawford, Hollie L Williams, Mahsima Shabani, Cassady J Pelphrey, Dakota D Grauherr, Kelsey Tomasek, Yan Ru Su, Megan C Lancaster, Quinn S Wells, Jeffrey M Dendy, Pablo Saavedra, Juan C Estrada, Travis D Richardson, Sharon T Shen, Arvindh N Kanagasundram, Jay A Montgomery, Christopher R Ellis, George H Crossley, Harikrishna Tandri, Prince J Kannankeril, Steven A Lubitz, William G Stevenson, Fei Ye, Patrick T Ellinor, Lynne W Stevenson, Dan M Roden, M Benjamin Shoemaker","doi":"10.1016/j.jacep.2024.07.029","DOIUrl":"https://doi.org/10.1016/j.jacep.2024.07.029","url":null,"abstract":"<p><strong>Background: </strong>TTN encodes a sarcomeric protein called titin. Pathogenic rare variants in TTN are the most common finding in patients with atrial fibrillation (AF) and positive genetic testing.</p><p><strong>Objectives: </strong>This study sought to define the characteristics and outcomes in patients with AF and pathogenic TTN variants compared with genotype-negative patients with AF.</p><p><strong>Methods: </strong>Patients who presented initially with AF were enrolled in an AF registry. Retrospectively they underwent research sequencing for cardiomyopathy and arrhythmia genes. TTN(+) AF cases were defined as participants with pathogenic or likely pathogenic (P/LP) rare variants located in exons with high cardiac expression. They were matched 1:2 with control subjects with no P/LP variants. Phenotyping used retrospective manual chart review.</p><p><strong>Results: </strong>Among 2794 participants; 57 (2.0%) TTN(+) AF cases were identified and matched with 114 control subjects. Low QRS complex voltage was present more often in TTN(+) AF cases (18% vs 5%; P < 0.01), with no difference in PR, QRS interval, or QTc. More TTN(+) AF cases had persistent AF at enrollment (44% vs 30%; P = 0.028) and had undergone multiple cardioversions (61% vs. 37%; P < 0.01). By end of follow-up (median 8.3 years; Q1, Q3: 4.5, 13.7 years), 11% of TTN(+) AF cases developed sustained ventricular tachycardia/ventricular fibrillation, 44% left ventricular (LV) systolic dysfunction (LV ejection fraction <50%), and 47% met a combined endpoint of sustained ventricular tachycardia/ventricular fibrillation or LV systolic dysfunction.</p><p><strong>Conclusions: </strong>TTN(+) AF patients undergo more cardioversions and have more persistent forms of AF. Approximately 50% develop LV systolic dysfunction and/or malignant ventricular arrhythmias. These results highlight the need for diagnostic evaluation and management in TTN(+) patients beyond the usual care for AF.</p>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-09-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142500585","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}