Jacqueline Joza

Temporal trends and sex differences in pulmonary vein isolation for patients with atrial fibrillation

BACKGROUND Indications for pulmonary vein isolation for the treatment of atrial fibrillation (AF) have expanded over the years. OBJECTIVE We aimed to describe trends in demographic and clinical characteristics of patients undergoing ablation, with a particular focus on sex differences. METHODS Patients who underwent first AF ablation between 2003 and 2012 were identified within an AF cohort by using Quebec administrative databases. Descriptive statistics and multivariable analysis were used to examine sex differences and temporal trends in demographic and clinical characteristics, as well as independent predictors of the ablation procedure. RESULTS A total of 2438 of 173,689 patients in the AF cohort underwent AF ablation. In the span of 10 years, the rate of AF ablation increased from 8.5 to 57.2 per million persons-an almost 7-fold increase. Patients undergoing ablation were younger than patients in the general AF cohort (57.4 ± 12.2 years vs 75.3 ± 12.0 years) and had fewer baseline comorbidities (56.7% vs 88.4%). Representing 42.9% of the general AF cohort, the annual proportion of women in the AF ablation cohort has not surpassed 30%, and men had a higher likelihood of undergoing ablation than did women (odds ratio 1.54; 95% confidence interval 1.40-1.69). Over the decade of observation, there were slight increases in patient age, comorbidities, and CHADS2 score, some of which reached clinical significance for men and/or women. CONCLUSION The uptake of AF ablation over 10 years has expanded, with an increasingly greater number of older patients and with increased presence of comorbidities; however, there has been no increase in the relatively low proportion of women undergoing AF ablation.

Substrate-guided ablation of haemodynamically tolerated and untolerated ventricular tachycardia in patients with structural heart disease: effect of cardiomyopathy type and acute success on long-term outcome

AIMS The purpose of this study was to evaluate the outcomes of purely substrate-guided ventricular tachycardia (VT) ablation in patients with non-ischaemic dilated cardiomyopathy (NIDCM) and ischaemic cardiomyopathy (ICM) and the impact of acute procedural success on long-term outcome. METHODS AND RESULTS One hundred and forty-two patients (65 ± 12 years old, 72% male) with ICM (n = 87) and with NIDCM (n = 55) underwent substrate-guided VT ablation. The ablation approach involved eliminating all LP regions and ablating all scar border zone regions with 10 or more out of 12 pace-matching. All patients were followed with regular implantable defibrillator interrogations for mean 641 ± 301 days. Complete acute success (no inducible VT) was achieved in 60 patients with ICM (69%) and in 29 patients with NIDCM (53%) (P = 0.03). Partial success (elimination of clinical VT only) was obtained in nine patients with ICM (10%) and in four patients with NIDCM (7%) (P = 0.14). Procedural failure (clinical VT still inducible) occurred in 18 patients within the ICM group (21%) and in 22 patients of the NIDCM (40%) (P = 0.04). Overall, 51 patients presented with recurrence of ventricular arrhythmias: 23 in the group with ICM (26%) and 28 in the group with NIDCM (51%) (P = 0.03). Long-term success was related to acute procedural outcome. CONCLUSIONS Substrate-guided ablation is an effective approach in the treatment of VT with long-term outcome directly related to acute procedural success. Success rates are significantly lower in patients with NIDCM compared with those with ICM.

Managing Novel Oral Anticoagulants in Patients With Atrial Fibrillation Undergoing Device Surgery: Canadian Survey

BACKGROUND Approximately 10% of patients who undergo surgical procedures require chronic oral anticoagulation. Physicians must balance the thromboembolic and bleeding risks to make informed decisions on whether to continue anticoagulant medication. Evidence is lacking regarding the perioperative management of novel oral anticoagulant (NOAC) agents. This survey aims to describe the management of perioperative NOAC use during device implantation by Canadian centres. METHODS A Web-based tool was used to survey all Canadian adult pacemaker/defibrillator implant centres. The survey collected data regarding the perioperative management of NOACs in atrial fibrillation patients at high risk for thromboembolism who undergo device implantation. RESULTS Twenty-two centres performed approximately 14,971 device implants; 1150 (8%) of these implants were in patients who were prescribed a NOAC. In 82% of centres, the NOAC is discontinued in anticipation of device implantation; 73% of these centres do not bridge with heparin. In patients with normal renal function at high risk of thromboembolic events (Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack; CHADS2 ≥ 2), 72% of the centres restart the NOAC within 48 hours of the procedure. For patients with abnormal renal function (glomerular filtration rate < 80 mL/min), the timing of NOAC discontinuation is variable. Hematoma rates vary from 0 to 30%. CONCLUSIONS Most Canadian centres perform device implantation with NOAC interruption without the use of bridging. The timing of stopping and restarting anticoagulation and incidence of bleeding complications is variable. These findings emphasize the need for randomized controlled studies to guide the optimal approach to management of NOACs during device implantation.

In-Hospital Management of Atrial Fibrillation: The CHADS2 Score Predicts Increased Cost

BACKGROUND Hospitalizations for atrial fibrillation (AF) impose a substantial burden on our health care system, and AF management strategies are increasingly focused on hospitalization reduction. The objectives of this study were to determine the cost of hospitalization for AF and to identify the main determinants of this cost in a Canadian setting. METHODS Our study population consisted of patients hospitalized for AF and/or atrial flutter at a tertiary care hospital in Canada between April 1, 2001, and March 31, 2007. Patient-level demographics and data on clinical resource use and cost of treatment were collected from a computerized resource use and cost accounting system. The main determinants of in-hospital costs were identified through Bayesian model averaging. RESULTS Data were collected on 325 consecutive hospitalizations for AF. The median length of stay was 5 days (interquartile range [IQR], 3-9). The mean cost of an AF admission was CAD

Prognostic value of atrial fibrillation inducibility after right atrial flutter ablation

4740 (SD = CAD

Therapy for ventricular arrhythmias in structural heart disease: a multifaceted challenge.

4457), and the median was CAD

Catheter ablation for the treatment of atrial fibrillation is associated with a reduction in health care resource utilization: SAMUEL et al .

3532 (IQR, CAD

Venous Thrombosis After Electrophysiology Procedures: A Systematic Review

2013-CAD

Assessment and Management of the Left Atrial Appendage Thrombus in Patients With Nonvalvular Atrial Fibrillation

5944). Multivariate analysis identified 2 independent predictors of increased cost: CHADS₂ score (relative increase in cost: 1.24; 95% CI, 1.16-1.33) and warfarin use (relative increase in cost: 1.41; 95% CI, 1.20-1.67). These 2 variables were also independent predictors of increased length of stay. CONCLUSIONS The main clinical determinants of increased cost and increased length of stay were CHADS₂ score and warfarin use. Strategies for reducing AF-related costs should focus on preventing hospitalization or decreasing its length in patients with high CHADS₂ scores and on finding alternatives to the use of warfarin or using outpatient bridging anticoagulation to facilitate earlier hospital discharge.

Long-term risk of stroke and bleeding post-atrial fibrillation ablation: JOZA et al.

BACKGROUND Patients with typical right atrial flutter (AFL) may also have underlying atrial fibrillation (AF) or be at high risk of developing AF. Inducibility of AF among patients undergoing AFL ablation may be an important predictor of future occurrence of AF and may be useful in guiding management of this patient population. OBJECTIVE This study aimed to determine whether inducibility of AF at the time of AFL ablation is independently associated with the risk of future AF. METHODS Attempt at induction of AF by burst pacing was performed in consecutive patients who underwent AFL ablation. Time to incidence of AF after AFL ablation was examined using multivariable Cox proportional hazards models. All analyses were stratified by a history of AF. RESULTS A total of 175 patients were retrospectively evaluated over a median follow-up period of 482 days. In patients without a documented history of AF (n = 93), the incidence of AF after AFL ablation was 18.7 per 100 person-years. In these patients, inducible AF was strongly associated with the future development of AF (adjusted hazard ratio 15.99; 95% confidence interval 5.10-50.12). In contrast, in patients with a documented history of AF (n = 82), the incidence of AF after AFL ablation was 59.3 per 100 person-years and inducible AF was not associated with the future development of AF (adjusted hazard ratio 1.26; 95% confidence interval 0.74-2.14). CONCLUSION Inducibility of AF after AFL ablation is strongly and independently associated with the risk of future AF among patients without a history of AF but not among patients with a history of AF.