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BACKGROUND: Enhanced characterization of the atrial electrical substrate may lead to better comprehension of atrial fibrillation (AF) pathophysiology. OBJECTIVE: With the use of high-density substrate mapping, we sought to investigate the occurrence of functional electrophysiological phenomena in the left atrium and to assess potential association with arrhythmia recurrences following catheter ablation. METHODS: Sixty-three consecutive patients with AF referred for ablation were enrolled. Conduction abnormalities analysis relied on two acquired left atrial electro-anatomical maps (sinus and atrial paced rhythm). We classified conduction abnormalities as fixed (if these were present in both rhythms), or functional rhythm-dependent (if unmasked in one of the two rhythms). Esophagus and aorta locations were recorded to check the correspondence with abnormal conduction sites. RESULTS: 234 conduction abnormalities were detected, of which 125 (53.4%) were functional rhythm-dependent. In sinus rhythm the most frequent anatomical site of functional phenomena was the anterior wall followed by the posterior wall and in paced rhythm, the pulmonary venous antra. Sites of functional phenomena in 82.6% of cases corresponded with extra-cardiac structures such as sinus of Valsalva of ascending aorta anteriorly and the esophagus posteriorly. The vast majority (88%) of areas with functional phenomena had normal bipolar voltage. After pulmonary vein ablation, the number of residual functional phenomena is an indipendent predictor of AF recurrence (HR 2.539 [1.458 - 4.420], p-value = 0.001) with a risk of recurrences at multivariable Cox analysis. CONCLUSIONS: Dual high-density mapping (during sinus and paced rhythms) is able to unmask functional, rhythm-dependent, phenomena which are predictive of AF recurrences during the follow-up.
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Introduction: Atrial fibrillation (AF) represents the most common arrhythmia in the postoperative setting. We aimed to investigate the incidence of postoperative AF (POAF) and determine its predictors, with a specific focus on inflammation markers. Methods: We performed a retrospective single tertiary center cohort study including consecutive adult patients who underwent a major surgical procedure between January 2016 and January 2020. Patients were divided into four subgroups according to the type of surgery. Results: Among 53,387 included patients (79.4% male, age 64.5 ± 9.5 years), POAF occurred in 570 (1.1%) with a mean latency after surgery of 3.4 ± 2.6 days. Ninety patients died (0.17%) after a mean of 13.7 ± 8.4 days. The 28-day arrhythmia-free survival was lower in patients undergoing lung and cardiovascular surgery (p < .001). Patients who developed POAF had higher levels of C-reactive protein (CRP) (0.70 ± 0.03 vs. 0.40 ± 0.01 log10 mg/dl; p < .001). In the multivariable Cox regression analysis, adjusting for confounding factors, CRP was an independent predictor of POAF [HR per 1 mg/dL increase in log-scale = 1.81 (95% CI 1.18-2.79); p = .007]. Moreover, independent predictors of POAF were also age (HR/1 year increase = 1.06 (95% CI 1.04-1.08); I < .001), lung and cardiovascular surgery (HR 23.62; (95% CI 5.65-98.73); p < .001), and abdominal and esophageal surgery (HR 6.26; 95% CI 1.48-26.49; p = .013). Conclusions: Lung and cardiovascular surgery had the highest risk of POAF in the presented cohort. CRP was an independent predictor of POAF and postsurgery inflammation may represent a major driver in the pathophysiology of the arrhythmia.
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BACKGROUND: Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. The aim of this review was to evaluate the progress made in the management of AF over the two last decades. RESULTS: Clinical classification of AF is usually based on the presence of symptoms, the duration of AF episodes and their possible recurrence over time, although incidental diagnosis is not uncommon. The majority of patients with AF have associated cardiovascular diseases and more recently the recognition of modifiable risk factors both cardiovascular and non-cardiovascular which should be considered in its management. Among AF-related complications, stroke and transient ischaemic accidents (TIAs) carry considerable morbidity and mortality risk. The use of implantable devices such as pacemakers and defibrillators, wearable garments and subcutaneous cardiac monitors with recording capabilities has enabled to access the burden of "subclinical AF". The recent introduction of non-vitamin K antagonists has led to improve the prevention of stroke and peripheral embolism. Agents capable of reversing non-vitamin K antagonists have also become available in case of clinically relevant major bleeding. Transcatheter closure of left atrial appendage represents an option for patients unable to take oral anticoagulation. When treating patients with AF, clinicians need to select the most suitable strategy, i.e. control of heart rate and/or restoration and maintenance of sinus rhythm. The studies comparing these two strategies have not shown differences in terms of mortality. If an AF episode is poorly tolerated from a haemodynamic standpoint, electrical cardioversion is indicated. Otherwise, restoration of sinus rhythm can be obtained using intravenous pharmacological cardioversion and oral class I or class III antiarrhythmic is used to prevent recurrences. During the last two decades after its introduction in daily practice, catheter ablation has gained considerable escalation in popularity. Progress has also been made in AF associated with heart failure with reduced or preserved ejection fraction. CONCLUSIONS: Significant progress has been made within the past 2 decades both in the pharmacological and non-pharmacological managements of this cardiac arrhythmia.
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Accidente Cerebrovascular , Antiarrítmicos/uso terapéutico , Anticoagulantes/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Trastorno del Sistema de Conducción Cardíaco/tratamiento farmacológico , Humanos , Accidente Cerebrovascular/prevención & controlRESUMEN
BACKGROUND: Mobile computing and communication technologies in health services and information (so-called mHealth) have modified the traditional approach in the follow-up of patients with implantable cardiac devices, increased patient engagement and empowerment, reduced healthcare costs and improved patients' outcome. Recent developments in mobile technology, with the introduction of smartphone-compatible devices that can measure various health parameters and transfer automatically generated data, have increased the potential application of remote monitoring and the interest towards mHealth. However, little is known about the patients' interest and expectations of this new technology. OBJECTIVE: The patients' interest in the possibility of receiving data from their implantable cardiac device, clinical and health advice via remote monitoring on their smartphones were investigated. METHODS: A questionnaire entitled 'Expectations for future possibility of self-management of device data' (Likert scale scored) was submitted to 300 consecutive implantable cardiac device outpatients. The questionnaire was focused on collecting patients' expectations in receiving direct information regarding their implantable cardiac device status (item 1, five questions), their own clinical status (item 2, seven questions) and advice on healthy lifestyle promotion (item 3, nine questions). Patient characteristics associated with greater interest towards mHealth were also investigated. RESULTS: Questionnaires were completed by 268 patients (221 men, aged 69 ± 14 years). The Cronbach test reported an alpha value of 0.98 for item 1, 0.94 for item 2 and 0.97 for item 3. Patients declared to be mainly interested in the device interventions (62%) and in severe arrhythmia occurrence (61%), followed by data on heart failure severity (54%) and their performed physical activity (48%). Patients showed very little interest in ECG tracing (37%), but the lowest interest was expressed towards healthy lifestyle promotion advice (<40%). A higher education degree and the presence of the caregiver positively affected the interest towards remote monitoring information ( P < 0.001). CONCLUSIONS: The patients' interests were mainly directed at receiving information related to technical data of the implantable cardiac device and not to the overall management of the disease, underlying the insufficient awareness of patients towards the key role of self-control health status and the promotion of a healthy lifestyle.