Anita Wokhlu

Long-Term Quality of Life After Ablation of Atrial Fibrillation The Impact of Recurrence, Symptom Relief, and Placebo Effect

OBJECTIVES We sought to determine the relationship between atrial fibrillation (AF) ablation efficacy, quality of life (QoL), and AF-specific symptoms at 2 years. BACKGROUND Although the primary goal of AF ablation is QoL improvement, this effect has yet to be demonstrated in the long term. METHODS A total of 502 symptomatic AF ablation recipients were prospectively followed for recurrence, QoL, and AF symptoms. RESULTS In 323 patients with 2 years of follow-up, 72% achieved AF elimination off antiarrhythmic drugs (AADs), 15% achieved AF control with AADs, and 13% had recurrent AF. The physical component summary scores of the Medical Outcomes Study Short Form 36 increased from 58.8 +/- 20.1 to 76.2 +/- 19.2 (p < 0.001) and the mental component summary scores of the Short Form 36 increased from 65.3 +/- 18.6 to 79.8 +/- 15.8 (p < 0.001). Post-ablation QoL improvements were noted across ablation outcomes, including recurrent AF (change in physical component summary: 12.1 +/- 19.7 and change in mental component summary: 9.7 +/- 17.9), with no significant differences in QoL improvement across 3 ablative efficacy outcomes. However, in 103 patients who completed additional assessment with Mayo AF Symptom Inventories (on a scale of 0 to 48), those with AF elimination off AADs had a change in AF symptom frequency score of -9.5 +/- 6.3, which was significantly higher than those with AF controlled with AADs (-5.6 +/- 3.8, p = 0.03) or those with recurrent AF (-3.4 +/- 8.4, p = 0.02). Independent predictors of limited QoL improvement included higher baseline QoL, obesity, and warfarin use at follow-up. CONCLUSIONS AF ablation produces sustained QoL improvement at 2 years in patients with and without recurrence. AF-specific symptom assessment more accurately reflects ablative efficacy.

Success of Ablation for Atrial Fibrillation in Isolated Left Ventricular Diastolic Dysfunction: A Comparison to Systolic Dysfunction and Normal Ventricular Function

Background— The efficacy of radiofrequency ablation for atrial fibrillation (AF) in patients with left ventricular (LV) systolic dysfunction and isolated diastolic dysfunction is uncertain. Methods and Results— A prospective cohort of patients with normal and abnormal LV function underwent ablation for antiarrhythmic drug (AAD)-refractory AF. Three groups were compared: 111 patients with systolic dysfunction, defined as LV ejection fraction (LVEF) ≤40%; 157 patients with isolated diastolic dysfunction but preserved LVEF ≥50%; and 100 patients with normal LV function. The primary end point was AAD-free AF elimination at 1 year after ablation. This end point was achieved in 62% of patients with systolic dysfunction, 75% of those with diastolic dysfunction, and 84% of controls ( P =0.007). AF control on or off AADs was achieved in 76% of patients with systolic dysfunction, 85% of those with diastolic dysfunction, and 89% of controls ( P =0.08). In the systolic dysfunction group, 49% experienced an increase in LVEF by ≥5% after ablation, of which 64% achieved normal LVEF. In the diastolic dysfunction group, 30% of patients demonstrated at least 1 grade improvement in diastolic dysfunction. Multivariable analysis demonstrated an increased relative risk of arrhythmia recurrence of 1.8 (95% CI, 1.1 to 3.1; P =0.02) in systolic dysfunction and 1.7 (1.0 to 2.7; P =0.04) in isolated diastolic dysfunction compared with normal function. Conclusions— Although an ablative approach for AF in patients with systolic or diastolic dysfunction is associated with an increased long-term recurrence risk, there is potential for substantial quality-of-life improvement and LV functional benefit.Background— The efficacy of radiofrequency ablation for atrial fibrillation (AF) in patients with left ventricular (LV) systolic dysfunction and isolated diastolic dysfunction is uncertain. Methods and Results— A prospective cohort of patients with normal and abnormal LV function underwent ablation for antiarrhythmic drug (AAD)-refractory AF. Three groups were compared: 111 patients with systolic dysfunction, defined as LV ejection fraction (LVEF) ⩽40%; 157 patients with isolated diastolic dysfunction but preserved LVEF ≥50%; and 100 patients with normal LV function. The primary end point was AAD-free AF elimination at 1 year after ablation. This end point was achieved in 62% of patients with systolic dysfunction, 75% of those with diastolic dysfunction, and 84% of controls (P=0.007). AF control on or off AADs was achieved in 76% of patients with systolic dysfunction, 85% of those with diastolic dysfunction, and 89% of controls (P=0.08). In the systolic dysfunction group, 49% experienced an increase in LVEF by ≥5% after ablation, of which 64% achieved normal LVEF. In the diastolic dysfunction group, 30% of patients demonstrated at least 1 grade improvement in diastolic dysfunction. Multivariable analysis demonstrated an increased relative risk of arrhythmia recurrence of 1.8 (95% CI, 1.1 to 3.1; P=0.02) in systolic dysfunction and 1.7 (1.0 to 2.7; P=0.04) in isolated diastolic dysfunction compared with normal function. Conclusions— Although an ablative approach for AF in patients with systolic or diastolic dysfunction is associated with an increased long-term recurrence risk, there is potential for substantial quality-of-life improvement and LV functional benefit.

Upgrade and de novo cardiac resynchronization therapy: Impact of paced or intrinsic QRS morphology on outcomes and survival

BACKGROUND Cardiac resynchronization therapy (CRT) improves outcomes in patients with left bundle branch block (LBBB), but the benefits of CRT in patients with other QRS morphologies or previous pacing are uncertain. OBJECTIVE The purpose of this study was to describe outcomes in patients with prior right ventricular pacing and non-LBBB morphologies. METHODS We studied 505 patients who underwent de novo CRT (n = 338) or CRT upgrade (n = 167). De novo patients were categorized by underlying QRS morphology: LBBB (67%), right bundle branch block (RBBB; 11%), intraventricular conduction delay (IVCD; 13%), and QRS <120 ms (9%). Upgrade patients were categorized by the percentage of previous ventricular pacing. RESULTS Patients were followed for death over a median of 2.6 years (interquartile range 1.6-4.0). New York Heart Association (NYHA) functional class and echocardiographic improvements were similar in de novo and upgrade patients. However, within the de novo group, NYHA improvements were less in patients with RBBB (0.3 +/- 0.8; P = .014) or IVCD (0.2 +/- 0.7; P = .001) than in those with LBBB (0.7 +/- 0.8). These patients had less left ventricular functional improvement as well. Survival was comparable after de novo versus upgrade CRT (61% vs 63% at 4 years; P = .906). No clinical or survival differences were noted in upgrade patients based on the percentage of previous pacing. However, survival in de novo CRT recipients with RBBB (32%) was lower than in those with LBBB (66%; P <.001), and RBBB independently predicted death (hazard ratio 3.5, confidence interval 1.9-6.5; P <.001). CONCLUSION RBBB and IVCD result in less clinical improvement or worsened survival after CRT. Additional selection criteria may be beneficial in identifying potential responders with RBBB, IVCD, or narrow QRS.

Cardiovascular risks and elevation of serum DHT vary by route of testosterone administration: a systematic review and meta-analysis

BackgroundPotential cardiovascular (CV) risks of testosterone replacement therapy (TRT) are currently a topic of intense interest. However, no studies have addressed CV risk as a function of the route of administration of TRT.MethodsTwo meta-analyses were conducted, one of CV adverse events (AEs) in 35 randomized controlled trials (RCTs) of TRT lasting 12 weeks or more, and one of 32 studies reporting the effect of TRT on serum testosterone and dihydrotestosterone (DHT).ResultsCV risks of TRT: Of 2,313 studies identified, 35 were eligible and included 3,703 mostly older men who experienced 218 CV-related AEs. No significant risk for CV AEs was present when all TRT administration routes were grouped (relative risk (RR) = 1.28, 95% confidence interval (CI): 0.76 to 2.13, P = 0.34). When analyzed separately, oral TRT produced significant CV risk (RR = 2.20, 95% CI: 1.45 to 3.55, P = 0.015), while neither intramuscular (RR = 0.66, 95% CI: 0.28 to 1.56, P = 0.32) nor transdermal (gel or patch) TRT (RR = 1.27, 95% CI: 0.62 to 2.62, P = 0.48) significantly altered CV risk. Serum testosterone/DHT following TRT: Of 419 studies identified, 32 were eligible which included 1,152 men receiving TRT. No significant difference in the elevation of serum testosterone was present between intramuscular or transdermal TRT. However, transdermal TRT elevated serum DHT (5.46-fold, 95% CI: 4.51 to 6.60) to a greater magnitude than intramuscular TRT (2.20-fold, 95% CI: 1.74 to 2.77).ConclusionsOral TRT produces significant CV risk. While no significant effects on CV risk were observed with either injected or transdermal TRT, the point estimates suggest that further research is needed to establish whether administration by these routes is protective or detrimental, respectively. Differences in the degree to which serum DHT is elevated may underlie the varying CV risk by TRT administration route, as elevated serum dihydrotestosterone has been shown to be associated with CV risk in observational studies.

Differential outcome of cardiac resynchronization therapy in ischemic cardiomyopathy and idiopathic dilated cardiomyopathy.

BACKGROUND Cardiac resynchronization therapy (CRT) is a therapy of proven benefit in patients with advanced heart failure. Identifying potential responders remains challenging, and whether the etiology of the heart failure is related to the potential hemodynamic benefit and long-term outcome of CRT is unclear. OBJECTIVE The purpose of this study was to evaluate whether heart failure etiology (ischemic cardiomyopathy [ICM] vs nonischemic dilated cardiomyopathy [DCM]) was associated with CRT outcome and implantable cardioverter-defibrillator (ICD) shocks. METHODS The study included 503 CRT recipients (CRT-D 90%) in a longitudinal CRT database: ICM (n = 312) and DCM (n = 191). Clinical variables and echocardiographic measures preimplant and postimplant were collected. Actuarial survival and ICD therapy data were assessed with Kaplan-Meier curve and log rank tests. RESULTS Pre-CRT, ICM patients were older and had higher creatinine levels (P <.001). At median follow-up of 7.1 months, the DCM group experienced greater improvement in left ventricular ejection fraction (8.3% ± 10% vs 6.2% ± 10%, P = .05) and left ventricular end-diastolic volumes than did those with ICM (-28%.4 ± 53 mL vs -15.3 ± 46 mL, P = .024). Survival estimates at 4 years were 55% for ICM and 77% for DCM groups (P <.001), respectively, whereas no significant difference in the incidence of appropriate/inappropriate ICD shocks was observed. The ICM group remained at higher risk for death compared to the DCM group after controlling for preimplant variables (hazard ratio 1.6, 95% confidence interval 1.1-2.3, P = .008). CONCLUSION In response to CRT and in contrast to ICM, DCM patients experienced greater improvement in left ventricular systolic function and reverse remodeling while also sustaining a greater survival benefit.

Safety of magnetic resonance imaging in patients with permanent pacemakers: a collaborative clinical approach

ObjectiveThis study aimed to characterize the interactions of pacemakers with magnetic resonance imaging (MRI) and to identify device characteristics that could predict adverse interactions.BackgroundThe safety of MRI in patients with indwelling pacemaker systems remains uncertain. Previous studies demonstrated safety in most patients, but unpredictable, potentially concerning changes in pacemaker behavior have occurred.MethodsWe prospectively studied patients with pacemaker devices in situ who were not pacemaker dependent and in whom MRI was essential for adequate diagnosis and treatment. All patients were monitored by electrocardiography and pulse oximetry during scanning; devices were interrogated and cardiac enzymes were measured before and after scanning.ResultsOf 32 patients studied (46 MRI examinations), 28 patients had a dual-chamber system and one had a biventricular device. Regions scanned were the head and spine. Devices were reprogrammed to asynchronous pacing or sense-only mode in all except six patients before MRI. During six scanning episodes (five patients), “power-on” resetting of the device was noted. Magnet-mode pacing was noted during four episodes (three patients). Occasional premature ventricular contractions were noted in one patient. No significant changes in battery voltage, sensed P wave and R wave, pacing thresholds, lead impedance, or cardiac enzymes were noted immediately after MRI or at 1-month follow-up.ConclusionsOverall, no significant changes were seen in pacemaker device function, and no adverse clinical events were observed. A minority of patients with older devices had unpredictable changes in device behavior, which stresses the need for close monitoring during and careful device interrogation after scanning.

RELATIONSHIP BETWEEN DIASTOLIC BLOOD PRESSURE AND ALL-CAUSE MORTALITY WITH LOWER SYSTOLIC BLOOD PRESSURE AMONG HYPERTENSIVE PATIENTS WITH CORONARY ARTERY DISEASE: LONG-TERM FOLLOW-UP OF THE US COHORT OF THE INTERNATIONAL VERAPAMIL SR-TRANDOLAPRIL STUDY (INVEST)

Background: A goal systolic blood pressure (SBP) ≤120mmHg reduced all-cause mortality in older SPRINT patients; however, implications of concomitantly lowering diastolic BP (DBP) with this goal are uncertain. Methods: 17,131 hypertensive subjects ≥50 yo with CAD were analyzed by SBP category (<

Simulation-based training of transesophageal echocardiography for cardiology fellows.

Cardiology fellows learn procedures by performing them on patients under faculty supervision. Such training may increase procedure times, compromise image quality, and cause complications. Simulators provide an opportunity to teach procedures where patients are not at risk. We created a simulation-based curriculum to teach transesophageal echocardiography (TEE) to first-year cardiology fellows and measured the change in their reported self-confidence in TEE skills.

Success of Ablation for Atrial Fibrillation in Isolated Left Ventricular Diastolic DysfunctionClinical Perspective: A Comparison to Systolic Dysfunction and Normal Ventricular Function

Background— The efficacy of radiofrequency ablation for atrial fibrillation (AF) in patients with left ventricular (LV) systolic dysfunction and isolated diastolic dysfunction is uncertain. Methods and Results— A prospective cohort of patients with normal and abnormal LV function underwent ablation for antiarrhythmic drug (AAD)-refractory AF. Three groups were compared: 111 patients with systolic dysfunction, defined as LV ejection fraction (LVEF) ≤40%; 157 patients with isolated diastolic dysfunction but preserved LVEF ≥50%; and 100 patients with normal LV function. The primary end point was AAD-free AF elimination at 1 year after ablation. This end point was achieved in 62% of patients with systolic dysfunction, 75% of those with diastolic dysfunction, and 84% of controls ( P =0.007). AF control on or off AADs was achieved in 76% of patients with systolic dysfunction, 85% of those with diastolic dysfunction, and 89% of controls ( P =0.08). In the systolic dysfunction group, 49% experienced an increase in LVEF by ≥5% after ablation, of which 64% achieved normal LVEF. In the diastolic dysfunction group, 30% of patients demonstrated at least 1 grade improvement in diastolic dysfunction. Multivariable analysis demonstrated an increased relative risk of arrhythmia recurrence of 1.8 (95% CI, 1.1 to 3.1; P =0.02) in systolic dysfunction and 1.7 (1.0 to 2.7; P =0.04) in isolated diastolic dysfunction compared with normal function. Conclusions— Although an ablative approach for AF in patients with systolic or diastolic dysfunction is associated with an increased long-term recurrence risk, there is potential for substantial quality-of-life improvement and LV functional benefit.Background— The efficacy of radiofrequency ablation for atrial fibrillation (AF) in patients with left ventricular (LV) systolic dysfunction and isolated diastolic dysfunction is uncertain. Methods and Results— A prospective cohort of patients with normal and abnormal LV function underwent ablation for antiarrhythmic drug (AAD)-refractory AF. Three groups were compared: 111 patients with systolic dysfunction, defined as LV ejection fraction (LVEF) ⩽40%; 157 patients with isolated diastolic dysfunction but preserved LVEF ≥50%; and 100 patients with normal LV function. The primary end point was AAD-free AF elimination at 1 year after ablation. This end point was achieved in 62% of patients with systolic dysfunction, 75% of those with diastolic dysfunction, and 84% of controls (P=0.007). AF control on or off AADs was achieved in 76% of patients with systolic dysfunction, 85% of those with diastolic dysfunction, and 89% of controls (P=0.08). In the systolic dysfunction group, 49% experienced an increase in LVEF by ≥5% after ablation, of which 64% achieved normal LVEF. In the diastolic dysfunction group, 30% of patients demonstrated at least 1 grade improvement in diastolic dysfunction. Multivariable analysis demonstrated an increased relative risk of arrhythmia recurrence of 1.8 (95% CI, 1.1 to 3.1; P=0.02) in systolic dysfunction and 1.7 (1.0 to 2.7; P=0.04) in isolated diastolic dysfunction compared with normal function. Conclusions— Although an ablative approach for AF in patients with systolic or diastolic dysfunction is associated with an increased long-term recurrence risk, there is potential for substantial quality-of-life improvement and LV functional benefit.

Success of Ablation for Atrial Fibrillation in Isolated Left Ventricular Diastolic DysfunctionClinical Perspective

Background— The efficacy of radiofrequency ablation for atrial fibrillation (AF) in patients with left ventricular (LV) systolic dysfunction and isolated diastolic dysfunction is uncertain. Methods and Results— A prospective cohort of patients with normal and abnormal LV function underwent ablation for antiarrhythmic drug (AAD)-refractory AF. Three groups were compared: 111 patients with systolic dysfunction, defined as LV ejection fraction (LVEF) ≤40%; 157 patients with isolated diastolic dysfunction but preserved LVEF ≥50%; and 100 patients with normal LV function. The primary end point was AAD-free AF elimination at 1 year after ablation. This end point was achieved in 62% of patients with systolic dysfunction, 75% of those with diastolic dysfunction, and 84% of controls ( P =0.007). AF control on or off AADs was achieved in 76% of patients with systolic dysfunction, 85% of those with diastolic dysfunction, and 89% of controls ( P =0.08). In the systolic dysfunction group, 49% experienced an increase in LVEF by ≥5% after ablation, of which 64% achieved normal LVEF. In the diastolic dysfunction group, 30% of patients demonstrated at least 1 grade improvement in diastolic dysfunction. Multivariable analysis demonstrated an increased relative risk of arrhythmia recurrence of 1.8 (95% CI, 1.1 to 3.1; P =0.02) in systolic dysfunction and 1.7 (1.0 to 2.7; P =0.04) in isolated diastolic dysfunction compared with normal function. Conclusions— Although an ablative approach for AF in patients with systolic or diastolic dysfunction is associated with an increased long-term recurrence risk, there is potential for substantial quality-of-life improvement and LV functional benefit.Background— The efficacy of radiofrequency ablation for atrial fibrillation (AF) in patients with left ventricular (LV) systolic dysfunction and isolated diastolic dysfunction is uncertain. Methods and Results— A prospective cohort of patients with normal and abnormal LV function underwent ablation for antiarrhythmic drug (AAD)-refractory AF. Three groups were compared: 111 patients with systolic dysfunction, defined as LV ejection fraction (LVEF) ⩽40%; 157 patients with isolated diastolic dysfunction but preserved LVEF ≥50%; and 100 patients with normal LV function. The primary end point was AAD-free AF elimination at 1 year after ablation. This end point was achieved in 62% of patients with systolic dysfunction, 75% of those with diastolic dysfunction, and 84% of controls (P=0.007). AF control on or off AADs was achieved in 76% of patients with systolic dysfunction, 85% of those with diastolic dysfunction, and 89% of controls (P=0.08). In the systolic dysfunction group, 49% experienced an increase in LVEF by ≥5% after ablation, of which 64% achieved normal LVEF. In the diastolic dysfunction group, 30% of patients demonstrated at least 1 grade improvement in diastolic dysfunction. Multivariable analysis demonstrated an increased relative risk of arrhythmia recurrence of 1.8 (95% CI, 1.1 to 3.1; P=0.02) in systolic dysfunction and 1.7 (1.0 to 2.7; P=0.04) in isolated diastolic dysfunction compared with normal function. Conclusions— Although an ablative approach for AF in patients with systolic or diastolic dysfunction is associated with an increased long-term recurrence risk, there is potential for substantial quality-of-life improvement and LV functional benefit.