Eric Black-Maier

Bucindolol hydrochloride in atrial fibrillation and concomitant heart failure

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia and it increases the risk of thromboembolic stroke and death. AF is common in patients with heart failure and reduced ejection fraction (HFrEF), affecting between 30 and 40% of patients with HFrEF. AF increases the risk of death and hospitalization in patients with HFrEF. Only two antiarrhythmic drugs (amiodarone and dofetilide) are guideline-recommended in patients with AF and heart failure (HF). Meta-analyses of studies of major trials in HF suggest that patients with AF/HFrEF do not benefit from conventional β-blockers. Bucindolol has shown promise in the treatment of patients with AF/HFrEF. We will explore how the shared pathophysiology of AF/HF is targeted by the unique pharmacology of bucindolol and review the existing data for bucindolol in AF/HF. We will explore findings that support a pharmacogenetically modulated effect of bucindolol in patients with polymorphisms in β1-adrenergic receptor and provide an overview of ongoing studies.

Ranolazine reduces atrial fibrillatory wave frequency.

Aims Antiarrhythmic medications for the treatment of atrial fibrillation (AF) have limited efficacy and rare but potentially life-threatening side effects. Ranolazine is an antianginal agent that may have antiarrhythmic activity in AF. Methods and results Using the Duke Enterprise Data Unified Content Explorer database, we analysed a cohort of AF patients on ranolazine. Patients served as their own historic control. Electrocardiograms (ECGs) were analysed before and after ranolazine initiation to determine the effect of ranolazine on dominant frequency (DF), f-wave amplitude, and organizational index (OI). We identified 15 patients with ECGs in AF before and after ranolazine. Ranolazine was associated with lower DF by an average of 10% (5.10 ± 0.74 vs. 5.79 ± 0.96 Hz, P = 0.04) but not with changes in OI (0.47 ± 0.11 vs. 0.50 ± 0.12, P = 0.71) or amplitude (0.47 ± 0.43 vs. 0.41 ± 0.40 mV, P = 0.82). Ranolazine was also associated with lower DF in patients (n = 10) not on concomitant antiarrhythmic therapy (5.25 ± 0.78 vs. 6.03 ± 0.79 Hz, P = 0.04). Conclusion Ranolazine is associated with lower AF DF but no change in OI or fibrillatory wave amplitude. Prospective trials are needed to evaluate ranolazines potential as a novel antiarrhythmic drug for AF.

Reply to the Editor— Contact force–sensing catheters and increased risk of atrioesophageal fistula: Is the tool to blame or the workmen?

1 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 We appreciate the interest and comments expressed by Das et al on force-time integral (FTI) targets for catheter ablation and the risk of atrioesophageal fistula formation. We agree that the application of a single FTI target to all areas of the left atrium is suboptimal (and potentially harmful) because of the variation in wall thickness and tissue architecture. It is certainly possible that targeting an FTI of 400 gs when ablating on the thin posterior wall may contribute to an increased risk of atrioesophageal fistula. We believe that there is a tremendous gap in knowledge, with few, if any, data to guide power and contact force delivery on the posterior wall. Das et al make an important contribution by identifying that an FTI of 230 gs on the posterior wall has a positive predictive value of 98.6% for no reconnection. However, validation of this threshold and other indices is needed, including those that incorporate power delivery. The use of acoustic radiation force imaging is one such way to validate these thresholds in vivo. However, analyses of large numbers of cases with specific data on ablation delivery during the procedure and postablation outcomes

Oral anticoagulation management in patients with atrial fibrillation undergoing cardiac implantable electronic device implantation

Oral anticoagulation (OAC) therapy is associated with increased periprocedural risks after cardiac implantable electronic device (CIED) implantation. Patterns of anticoagulation management involving non–vitamin K antagonist oral anticoagulants (NOACs) have not been characterized.