Beny Hartono

CHADS2 and CHA2DS2-VASc Scores in the Prediction of Clinical Outcomes in Patients With Atrial Fibrillation After Catheter Ablation

OBJECTIVES This study aimed to evaluate whether CHADS(2) and CHA(2)DS(2)-VASc scores are useful for risk stratification in patients after catheter ablation of atrial fibrillation (AF). BACKGROUND AF is associated with increased risk of cardiovascular events. However, limited data are available on the predictors of adverse events in patients with AF after catheter ablation. METHODS A total of 565 patients with AF who underwent catheter ablation were enrolled in the study. The clinical endpoint was occurrence of thromboembolic events (ischemic stroke, transient ischemic attack, peripheral embolism, or pulmonary embolisms) or death during follow-up after catheter ablation. RESULTS During a follow-up of 39.2 ± 22.6 months, 27 patients (4.8%) experienced adverse events. Both the CHADS(2) and CHA(2)DS(2)-VASc scores were useful predictors of events in separate multivariate models. The areas under the receiver-operator characteristic curves based on the CHADS(2) and CHA(2)DS(2)-VASc scores in predicting events were 0.785 and 0.830, respectively. Although the difference did not reach statistical significance (p = 0.116), the CHA(2)DS(2)-VASc score could be used to further stratify the patients with CHADS(2) scores of 0 or 1 into 2 groups with different event rates (7.1% vs. 1.1%, p = 0.003) at a cutoff value of 2. CONCLUSIONS The CHADS(2) and CHA(2)DS(2)-VASc scores are useful predictors of adverse events after catheter ablation of AF.

Clinical outcome of catheter ablation in patients with nonparoxysmal atrial fibrillation: results of 3-year follow-up.

Background—Catheter ablation of atrial fibrillation (AF) became an effective therapy for patients with drug-refractory AF, and the indications have broadened to include nonparoxysmal AF patients. However, data about the long-term effectiveness of ablation in patients with nonparoxysmal AF are lacking. The aim of the present study was to investigate the long-term outcomes of catheter ablation in patients with nonparoxysmal AF. Methods and Results—A total of 88 nonparoxysmal AF patients who received a stepwise catheter ablation (isolation of the pulmonary veins plus substrate modification) from 2006 to 2008 were enrolled. Freedom of recurrence was defined as the absence of atrial arrhythmias without using any antiarrhythmic agents after the catheter ablation. There were 63 patients (71.6%) with recurrences (47 patients with AF and 16 patients with atrial flutter/atrial tachycardia) after the initial procedure during a median follow-up period of 36.8 months. A CHADS2 score of ≥3 and the left atrial (LA) diameter were significant predictors of recurrences in the multivariable analysis. Of the patients with CHADS2 scores of ≥3 and an LA dimension ≥44 mm, all had recurrences within 1 year after the initial procedure. The overall recurrence-free rate could increase to 47.7% after the second procedure and 51.1% after the third procedure. Conclusions—The long-term recurrence-free rate of ablation in nonparoxysmal AF was only 28.4% after a single procedure, and multiple procedures were necessary to raise the recurrence-free rate. The CHADS2 score and LA dimension may help us to identify patients who will have recurrences after catheter ablations of nonparoxysmal AF.

Relationship between the CHADS2 score and risk of very late recurrences after catheter ablation of paroxysmal atrial fibrillation

BACKGROUND Catheter ablation of paroxysmal atrial fibrillation has been performed for more than 10 years. However, data about the long-term results were limited. OBJECTIVES To evaluate the long-tem efficacy following paroxysmal atrial fibrillation ablation and to investigate whether there were different patterns of recurrences in patients with different CHADS(2) scores. METHODS A total of 238 patients with paroxysmal atrial fibrillation who received a catheter ablation from 2004 to 2007 were enrolled. Free of recurrence was defined as the absence of atrial arrhythmias without using any antiarrhythmic agents after ablation. RESULTS There were 121 patients (50.8%) suffering from recurrences after the first ablation procedure during a median follow-up period of 5 years. The CHADS(2) score and left atrial diameter were significant predictors of recurrences in the multivariate analysis. Different patterns of recurrence were observed in different groups of patients categorized on the base of CHADS(2) score. Among patients with a CHADS(2) score of ≥3 without recurrences at 2 years postablation, 63.6% experienced episodes of arrhythmias during the subsequent follow-up period. In contrast, in patients with a CHADS(2) score of 0 without recurrences at 2 years postablation, the future recurrence rate was only 2.7%. CONCLUSIONS After a successful ablation, recurrences may continue to occur without reaching a plateau during the long-term follow-up, especially in patients with a high CHADS(2) score. The optimal follow-up strategy may differ and should be individualized for patients with different scores.

Associations among the CHADS2 score, atrial substrate properties, and outcome of catheter ablation in patients with paroxysmal atrial fibrillation

BACKGROUND The CHADS₂ score (congestive heart failure, hypertension, age >75 years, diabetes, and previous stroke/transient ischemic attack) is used for the risk stratification of strokes in patients with atrial fibrillation (AF). OBJECTIVE This study aimed to investigate the associations between the CHADS₂ score, atrial substrate, and outcome of catheter ablation in patients with paroxysmal AF. METHODS A total of 247 paroxysmal AF patients who received catheter ablation were enrolled. The patients were divided into 3 groups according to their CHADS₂ score (group 1: score 0, group 2: score 1 to 2, and group 3: score 3 to 6). The bi-atrial substrate properties and outcome of catheter ablation were analyzed. RESULTS The CHADS₂ scores in these 3 groups were 0 (group 1), 1.24 ± 0.48 (group 2), and 3.60 ± 0.83 (group 3), respectively. The left atrial voltage became lower (group 1 vs. 2 vs. 3 = 2.08 ± 0.73 mV vs. 1.80 ± 0.81 mV vs. 1.06 ± 0.69 mV) and the activation time longer (group 1 vs. 2 vs. 3 = 93.4 ± 17.7 ms vs. 101.9 ± 21.2 ms vs. 112.2 ± 21.7 ms), whereas the CHADS₂ score increased. During a follow-up of 17.3 ± 7.0 months, 23.1% of the study population suffered from recurrences. The recurrence rates of these 3 groups were 13.0% (group 1), 27.6% (group 2), and 45.9% (group 3), respectively. The groups of different CHADS₂ scores remained as the independent predictor of recurrence in the multivariate analysis. CONCLUSION A high CHADS₂ score was associated with different left atrial substrate properties and a poor outcome after catheter ablation of paroxysmal AF.

Renal dysfunction and the risk of thromboembolic events in patients with atrial fibrillation after catheter ablation—The potential role beyond the CHA2DS2-VASc score

BACKGROUND Renal dysfunction is recognized as an important risk factor for thromboembolic (TE) events in patients with atrial fibrillation (AF) under medical treatment. OBJECTIVE To investigate whether renal dysfunction is a useful predictor of TE events among patients receiving AF ablation. We also aimed to determine whether the diagnostic accuracy of the CHA(2)DS(2)-VASc score in predicting TE events could be improved by adding renal dysfunction into the scoring system. METHODS We enrolled a total of 547 patients with AF who underwent catheter ablation. Renal dysfunction was defined as an estimated glomerular filtration rate of <60 mL/min/1.73 m(2). The clinical end point was the occurrence of TE events (ischemic stroke, transient ischemic attack, or other systemic embolisms) during follow-up after catheter ablation. RESULTS During a follow-up of 38.9 ± 22.5 months, 16 patients (2.9%) experienced TE events. Both the CHA(2)DS(2)-VASc score and renal dysfunction were independent predictors of TE events in the multivariate analysis. Among patients with a CHA(2)DS(2)-VASc score of 0 or 1, renal dysfunction can further stratify them into 2 groups with different event rates (4.3% vs 0.3%; P = .046). A new scoring system derived by assigning 1 more point representing renal dysfunction to the CHA(2)DS(2)-VASc score could improve its predictive accuracy; the area under the receiver operating characteristic curve increased from 0.84 to 0.88 (P = .043). CONCLUSIONS Renal dysfunction was a significant risk factor for TE events after catheter ablation of AF and may improve the diagnostic accuracy of the CHA(2)DS(2)-VASc score.

Novel assessment of temporal variation in fractionated electrograms using histogram analysis of local fractionation interval in patients with persistent atrial fibrillation.

Background—The characteristics of atrial electrograms associated with atrial fibrillation (AF) termination are controversial. We investigated the electrogram characteristics that indicate procedural AF termination during continuous complex fractionated electrogram ablation. Methods and Results—Fifty-two consecutive patients with persistent AF (47 men; aged 54±9 years), who underwent electrogram-based catheter ablation in the left atrium and coronary sinus after pulmonary vein isolation, were enrolled. The intracardiac bipolar atrial electrogram recordings were characterized by (1) fractionation interval (FI) analysis (>6 seconds), (2) kurtosis (shape of the FI histogram), and (3) skewness (asymmetry of the FI histogram). Sites showing complex, fractionated electrograms (mean FI ⩽60 ms) were targeted, and AF was terminated in 20 patients (38%) after the pulmonary vein isolation. The conventional complex fractionated electrogram sites (mean ⩽120 ms) in patients with AF termination exhibited higher median kurtosis (2.69 [interquartile range, 2.03–3.46] versus 2.35 [interquartile range, 1.79–2.48]; P=0.024) and higher complex fractionated electrogram-mean interval (102.7±19.8 versus 87.7±15.0; P=0.008) than patients without AF termination. Furthermore, AF termination sites had higher median kurtosis than targeted sites without AF termination (5.13 [interquartile range, 3.51–6.47] versus 4.18 [interquartile range, 2.91–5.34]; P<0.01) in patients with procedural termination. In addition, patients with AF termination had a higher sinus rhythm maintenance rate after a single procedure than patients without AF termination (log-rank test, P=0.007). Conclusions—A kurtosis analysis using the FI histogram may be a useful tool in identifying the critical substrate for persistent AF and potential responders to catheter ablation.

Successful percutaneous coronary intervention for chronic total occlusion of right coronary artery in patient with dextrocardia.

Situs inversus with dextrocardia is rare congenital anomaly. Coronary artery disease in such patients is quite rare. We reported a 52-year-old man with dextrocardia and chronic total occlusion at the proximal right coronary artery just after conus branch and severe stenosis at the proximal left anterior descending artery. He underwent successful percutaneous coronary intervention with stenting of total occluded right coronary artery and simultaneously stenting of the proximal left anterior descending artery.

Left ventricular lead positioning in cardiac resynchronization therapy: an innovative retrograde approach without using snare

AIMS Ideal positioning of left ventricular (LV) pacing lead in cardiac resynchronization therapy (CRT) is technically demanding. This case aims to place LV lead in anterolateral branch of coronary sinus (CS) using collateral route blindly. METHODS AND RESULTS Externalization via the CS ostium using collaterals retrogrogradely, which was not visible in initial balloon occlusion venography, through one delivery sheath with the support of commonly used micro-guide catheter and subsequent successful LV lead placement in anterolateral branch of CS. CONCLUSION This innovative retrograde approach for LV pacing lead implantation in anterolateral branch of CS obviated the need for snare technique to capture the distal end of the wire when antegrade route was not successful.

Right atrial substrate remodeling and atrioventricular node conduction properties in patients with paroxysmal atrial fibrillation

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Impact of Oral Thrombolysis After Catheter-based Thrombectomy in Acute and Subacute Submassive Pulmonary Thromboembolism

Pulmonary thromboembolism (PTE) is a relatively common cardiovascular emergency and massive PTE has always been a major source of morbidity and mortality.[1] The traditional window period for thrombolysis in patients presenting with acute PTE is two weeks.[2] We present a series of three patients with sub-massive PTE, out of which two patients had acute and one patient subacute presentation. They had initially undergone catheter-based pulmonary embolectomy and intrapulmonary thrombolysis, but there was incomplete resolution of the thrombus in all three patients 48 hours after the procedures. Subsequently, they were treated with oral thrombolytic therapy (Lumbrokinase) for 12 weeks and all the patients had complete resolution of thrombus at three months follow-up and made a full recovery. To the best of our knowledge, the above-mentioned novel approach combined with adjunctive oral thrombolytic therapy is being reported for the first time. Case 1 A 49-year-old Indonesian man, hypertensive and diabetic, presented with a three-week history of progressive dyspnea and chest pain, especially during breathing and one week history of hemoptysis prior to admission. On presentation, he was hemodynamically stable with oxygen saturation >95% on room air. The electrocardiogram (ECG) showed normal sinus rhythm. Laboratory analysis revealed a fibrin degradation test (D-Dimer) result of 4.08 μg/ml, Troponin I 0.19 ng/ml, and NT-ProBNP 2094 pg/ml. Computed tomography of pulmonary angiogram (CTPA) showed a large filling defect in the right pulmonary artery (PA) and a minimal filling defect in the left PA [Figure 1, pre-procedure, case 1]. The right ventricle (RV) was dilated. Catheter-based pulmonary thrombectomy was performed followed by intrapulmonary thrombolysis with Streptokinase for the next 10 hours. Repeat CTPA 48 hours post-procedure (pre-discharge) showed resolution of the thrombus in the left PA, but there was still a small thrombus in the right PA [Figure 1, pre-discharge, case 1]. Figure 1 Pre procedure. Case 1: CTPA showing a large filling defect in the RPA (big arrow) and a minimal filling defect in the LPA (small arrow). Case 2: CTPA showing a large thrombus in the RPA (big arrow) and LPA (small arrow). Case 3: CTPA showing a large filling ... The patient was discharged with dual antiplatelet and oral thrombolytic. Two capsules of Thromboles® (The Institute of Biophysics, Chinese Academy of Sciences, Beijing, China) each containing 250 mg of Lumbrokinase extract equivalent to 300,000 units of Lumbrokinase derived from an artificially cultured Lumbricus strain, were administered three times daily for 12 weeks. Follow-up CTPA at three months showed complete resolution of the thrombus in the right PA [Figure 1, follow up three months, case 1]. Case 2 A 37-year-old man, non-hypertensive and non-diabetic, presented with chest pain and dyspnea at rest for the previous one week prior to admission. He was hemodynamically stable. ECG showed sinus rhythm with T-wave inversion in V1-4. Laboratory results showed D-Dimer 5 μg/ml, Troponin I 0.35 ng/ml, and NT-ProBNP 5965 pg/ml. CTPA showed extensive thrombi in both left and right PAs [Figure 1, pre-procedure, case 2] and dilatation of the RV. Catheter-based pulmonary thrombectomy was performed, followed by intrapulmonary thrombolysis with Streptokinase for the next 10 hours. Repeat CTPA was performed 48 hours after the procedure (pre-discharge) and still showed thrombus in both PAs [Figure 1, pre-discharge, case 2]. He was discharged with dual anti-platelet and oral thrombolytic (two capsules of Thromboles were administered three times daily for 12 weeks). Follow-up CTPA at three months showed complete resolution of thrombus in both PAs [Figure 1, follow up three months, case 2]. There was also T-wave resolution in the precordial leads of an ECG at three months. Case 3 A 70-year-old man presented with sudden onset of shortness of breath for the previous 24 hours prior to admission. ECG showed sinus rhythm with T wave inversion in V1–3. Laboratory results showed D-Dimer 0.62 μg/ml, Troponin I 0.22 ng/ml, and NT-Pro BNP 934 pg/ml. CTPA showed extensive thrombus in the right PA and a small thrombus in the left PA [Figure 1, pre-procedure, case 3] along with RV dilatation. Catheter-based pulmonary thrombectomy was performed, followed by intrapulmonary thrombolysis with Streptokinase for the next 10 hours. Repeat CTPA 48 hours after the procedure still showed some thrombus in the right PA [Figure 1, pre-discharge, case 3, although showed no thrombus at both RPA and LPA but in Figure 2, case 3, pre-discharge still showed a thrombus at the branch of RPA] and the ECG showed T-wave resolution in the precordial leads. Figure 2 Case 3: RPA and LPA did not show the filling defect (see figure 1), but the thrombus was clearly seen in the right superior anterior branch of the RPA during pre-discharge which was completely resolved at 3 months follow up. RPA denotes right pulmonary ... He was discharged with dual antiplatelet and oral thrombolytic (two capsules of Thromboles were administered three times daily for 12 weeks). Follow-up CTPA at three months showed complete resolution of thrombus in right PA [Figure 1, follow up three months, case 3 and Figure 2, case 3, follow up three months].