Jelena Kornej

Renal Dysfunction, Stroke Risk Scores (CHADS2, CHA2DS2-VASc and R2CHADS2) and the Risk of Thromboembolic Events after Catheter Ablation of Atrial Fibrillation: The Leipzig Heart Center AF Ablation Registry

Background— There are limited data on the predictive value of stroke risk scores for thromboembolic events (TEs) after catheter ablation of atrial fibrillation (AF). Our objectives were to report the incidence of TEs after AF ablation in a large contemporary AF ablation cohort and to investigate the impact of renal dysfunction and the value of stroke risk stratification scores (CHADS2, CHA2DS2-VASc, and R2CHADS2) for predicting TE after AF ablation. Methods and Results— Using the Leipzig Heart Center AF Ablation Registry, we documented TEs in patients undergoing radiofrequency AF catheter ablation. TE was defined as stroke, transient ischemic attack, or systemic embolism. Study population (N=2069; 66% men; 60±10 years; 62% paroxysmal AF; mean CHADS2, 1.2±0.9; CHA2DS2-VASc, 2.1±1.4; and R2CHADS2, 1.3±1.1) were followed up for a median 18 (Q1–Q3, 12–29) months (ie, 3078 patient-years). Overall, 31 TEs occurred, with 16 events within 30 days of ablation and 15 TEs (0.72%) during the follow-up period. On multivariate analysis, CHADS2 (P<0.001), R2CHADS2 (P<0.001), and CHA2DS2-VASc (P=0.003) scores were independent predictors of TEs during follow-up, and AF recurrence conferred a nonsignificant trend for increased TE risk (P=0.071–0.094). The CHA2DS2-VASc score further differentiated TE risk in patients with CHADS2 and R2CHADS2 0 to 1 (0.13% if CHA2DS2-VASc was 0–1 and 0.71% if CHA2DS2-VASc was >2) and had the best predictive value in patients with AF recurrences (c-index 0.894, P=0.022 versus CHADS2, P=0.031 versus R2CHADS2). Conclusions— CHADS2, CHA2DS2-VASc, and R2CHADS2 scores were associated with TE risk. The CHA2DS2-VASc score differentiated TE risk in the low-risk strata based on CHADS2 and R2CHADS2 scores and may be superior in the subgroup with AF recurrences.

The emerging role of biomarkers in atrial fibrillation.

Improved diagnostic techniques have identified various biomarkers that might play an important role in prediction of atrial fibrillation (AF) and related outcomes (cardio- and cerebrovascular events, and mortality and rhythm outcomes). Biomarkers can include blood markers (e.g., von Willebrand factor, D-dimer, natriuretic peptides, etc.), urine (e.g., proteinuria, estimated glomerular filtration rate, or creatinine clearance), cardiac imaging (echocardiography; transthoracic or transoesophageal), or cerebral imaging (e.g., computed tomography or magnetic resonance imaging), which can provide additional refinement to clinical stroke risk stratification for identification of high risk subjects. Although inclusion of some blood-based biomarkers (e.g., von Willebrand factor, D-dimer) in existing clinical stroke risk stratification schemes might improve their predictive value for identifying high risk patients, this concept might be outdated and overtaken by new developments in thromboprophylaxis (which now focus on initial identification of low risk patients who do not need any antithrombotic therapy, followed by patients with 1 or more stroke risk factors, to whom anticoagulation can be offered), and additional questionable practicality in everyday practice. Biomarkers could be applied as a rule out approach or as surrogates of anticoagulation efficacy in trials of new antithrombotic strategies. The present review aims to provide an update of the role of biomarkers in AF, with particular focus on AF outcomes.

Early cerebral thromboembolic complications after radiofrequency catheter ablation of atrial fibrillation: Incidence, characteristics, and risk factors

BACKGROUNDnThromboembolic complications remain one of the most severe adverse events associated with catheter ablation of atrial fibrillation (AF), but data on such events are limited.nnnOBJECTIVEnThe purpose of this study was to evaluate the incidence, characteristics, and risk factors of thromboembolic complications after AF ablation.nnnMETHODSnCerebral thromboembolic complications occurring within 1 month of 3360 consecutive AF radiofrequency catheter ablations were assessed. Stroke was defined as a neurologic deficit lasting more than 24 hours or with imaging study showing new infarction. Transient ischemic attack (TIA) was defined as a deficit lasting less than 24 hours and without documented infarction.nnnRESULTSnThere were 17 peri-interventional cerebral thromboembolic events (0.5%). Nine cases (53%) were diagnosed as strokes and 8 (47%) as TIAs. Sixty percent of the events occurred within 48 hours after the ablation; the rest occurred within 1 week. In univariate analysis, peri-interventional thromboembolism was associated with peripheral vascular disease (P = .010), impaired left ventricular ejection fraction (P = .040), periprocedural bridging with heparin (P = .007), and previous stroke (P = .026). Multivariable analysis demonstrated that peripheral vascular disease (odds ratio [OR] 8.81, confidence interval [CI] 1.61-48.31, P = .012) and previous stroke (OR 6.13, CI 1.18-31.91, P = .031) were independent predictors. In a different model, the CHA2DS2-VASc score was associated with thromboembolism (OR 1.35, CI 1.00-1.80, P = .049).nnnCONCLUSIONnCerebral thromboembolic complications after AF radiofrequency catheter ablation are rare. They mostly occur within 48 hours after the procedure and remain without lasting neurologic deficits in the majority of cases. Such complications are associated with peripheral vascular disease, previous stroke, and the CHA2DS2-VASc score.

Sex-related predictors for thromboembolic events after catheter ablation of atrial fibrillation: The Leipzig Heart Center AF Ablation Registry

BackgroundFemales with atrial fibrillation (AF) are at increased risk for ischemic stroke but have been under-represented in AF ablation cohorts. Whether the incidence of TE in women after catheter ablation is higher is unknown. We aimed to analyze the predictive value of thromboembolic scores and other clinical variants for thromboembolism (TE) after AF catheter ablation, separately in women and men.MethodsTE was combined endpoint of early (within first month) and late (during long-term follow-up) stroke, transient ischemic attack, or systemic embolism. Oral anticoagulation was prescribed for 6xa0months after catheter ablation and discontinued if CHADS2 wasxa0<2 and no AF recurrences were documented.ResultsThe study population (nxa0=xa02,069, 66xa0% male, 60xa0±xa010xa0years; 62xa0% paroxysmal AF) was followed for a median of 18xa0months (IQR 12–29). Overall 31 TE (1.5xa0%) occurred with 16 events within 30xa0days of ablation and 15 TE during the follow-up. Fourteen females (2.0xa0%) and 17 males (1.2xa0%) suffered TE (pxa0=xa00.128). On multivariate analysis, higher CHADS2 (HR 1.65, 95xa0% CI 1.10–2.47, pxa0=xa00.015), CHA2DS2-VASc (HR 1.42, 95xa0% CI 1.03–1.96, pxa0=xa00.034), R2CHADS2 (HR 1.76, 95xa0% CI 1.32–2.35, pxa0<xa00.001) scores, and eGFRxa0<60xa0ml/min/1.73xa0m2 (HR 3.95, 95xa0% CI 1.23–12.7, pxa0=xa00.021) were significantly associated with TE in men. In females, LV-EF (HR 0.95, 95xa0% CI 0.91–0.99, pxa0=xa00.021) and CHA2DS2-VASc score (HR 1.52, 95xa0% CI 1.01–2.28, pxa0=xa00.044) remained significant predictors for TE.ConclusionTE rates after AF catheter ablation are low in both genders. In females, LV-EF and CHA2DS2-VASc score and in males all three scores and renal dysfunction were associated with TE.

Effects of Radiofrequency Catheter Ablation of Atrial Fibrillation on Soluble P-Selectin, Von Willebrand Factor and IL-6 in the Peripheral and Cardiac Circulation

Background Catheter ablation (CA) of atrial fibrillation (AF) is associated with inflammatory response, endothelial damage and with increased risk of thrombosis. However, whether these processes differ in peripheral and cardiac circulation is unknown. Methods Plasma markers (von Willebrand factor (vWf), soluble P-selectin (sPsel) and interleukin-6 (IL-6)) were measured by ELISA at three time points in 80 patients (62±10 years, 63% males, 41% paroxysmal AF) undergoing CA. These were at baseline – from femoral vein (FV) and left atrium (LA) before ablation; directly after ablation – from the pulmonary vein (PV), LA and FV; and 24 hours after procedure – from a cubital vein (CV). Results The levels of vWF and IL6 – but not sP-sel – increased significantly 24h after procedure (p<0.001). Baseline vWF was significantly associated with persistent AF (Betau200a=u200a.303, pu200a=u200a0.006 and Betau200a=u200a.300, pu200a=u200a0.006 for peripheral and cardiac levels, respectively), while persistent AF (Betau200a=u200a.250, pu200a=u200a0.031) and LAA flow pattern (Betau200a=u200a.386, p<0.001) remained associated with vWF in cardiac blood after ablation. Advanced age was significantly associated with IL6 levels at baseline and after ablation in peripheral and cardiac blood. There were no clinical, procedural or anti-coagulation characteristics associated with sP-sel levels in cardiac blood, while peripheral sP-sel levels were associated with hypertension before (Betau200a=u200a−.307, pu200a=u200a0.007) and with persistent AF after ablation (Betau200a=u200a−.262, pu200a=u200a0.020). Conclusions vWF levels are higher in persistent AF and are associated with LAA rheological pattern after AF ablation. Increase of peripheral vWF and IL6 levels after procedure supports current AF ablation management with careful control of post-procedural anticoagulation to avoid ablation-related thromboembolism.

Rhythmuskontrolle nach Katheterablation von Vorhofflimmern

Atrial fibrillation (AF) occurs as the result of numerous complex physiological processes in the atria leading to AF promotion and maintenance. Improved diagnostic techniques have identified various biomarkers which may play an important role in the prediction of AF related outcomes (cardio- and cerebrovascular events, as well as mortality and rhythm outcomes). Biomarkers refer to biological markers and biomarkers in blood, urine as well as imaging marker (eg, dimensions (left atrial diameter and volume), anatomical features (left appendage and pulmonary vein anatomy), and physiological pattern (LAA flow velocity)) may play important role(s) as clinically important indices in relation to outcomes after different therapeutic strategies. However, the main domain in the biomarker field has focused on blood-based biomarkers, which are widely used to predict therapeutic success regarding underlying pathophysiological mechanism, such as inflammation, fibrosis, endothelial damage. This review provides an update of the role of clinically relevant biomarkers in AF, with particular focus on AF rhythm outcomes.Atrial fibrillation (AF) occurs as the result of numerous complex physiological processes in the atria leading to AF promotion and maintenance. Improved diagnostic techniques have identified various biomarkers which may play an important role in the prediction of AF related outcomes (cardio- and cerebrovascular events, as well as mortality and rhythm outcomes). Biomarkers refer to ‘biological markers’ and biomarkers in blood, urine as well as imaging marker (eg, dimensions (left atrial diameter and volume), anatomical features (left appendage and pulmonary vein anatomy), and physiological pattern (LAA flow velocity)) may play important role(s) as clinically important indices in relation to outcomes after different therapeutic strategies. However, the main domain in the biomarker field has focused on blood-based biomarkers, which are widely used to predict therapeutic success regarding underlying pathophysiological mechanism, such as inflammation, fibrosis, endothelial damage. This review provides an update of the role of clinically relevant biomarkers in AF, with particular focus on AF rhythm outcomes.

Rhythm outcomes after catheter ablation of atrial fibrillation. Clinical implication of biomarkers.

Atrial fibrillation (AF) occurs as the result of numerous complex physiological processes in the atria leading to AF promotion and maintenance. Improved diagnostic techniques have identified various biomarkers which may play an important role in the prediction of AF related outcomes (cardio- and cerebrovascular events, as well as mortality and rhythm outcomes). Biomarkers refer to biological markers and biomarkers in blood, urine as well as imaging marker (eg, dimensions (left atrial diameter and volume), anatomical features (left appendage and pulmonary vein anatomy), and physiological pattern (LAA flow velocity)) may play important role(s) as clinically important indices in relation to outcomes after different therapeutic strategies. However, the main domain in the biomarker field has focused on blood-based biomarkers, which are widely used to predict therapeutic success regarding underlying pathophysiological mechanism, such as inflammation, fibrosis, endothelial damage. This review provides an update of the role of clinically relevant biomarkers in AF, with particular focus on AF rhythm outcomes.Atrial fibrillation (AF) occurs as the result of numerous complex physiological processes in the atria leading to AF promotion and maintenance. Improved diagnostic techniques have identified various biomarkers which may play an important role in the prediction of AF related outcomes (cardio- and cerebrovascular events, as well as mortality and rhythm outcomes). Biomarkers refer to ‘biological markers’ and biomarkers in blood, urine as well as imaging marker (eg, dimensions (left atrial diameter and volume), anatomical features (left appendage and pulmonary vein anatomy), and physiological pattern (LAA flow velocity)) may play important role(s) as clinically important indices in relation to outcomes after different therapeutic strategies. However, the main domain in the biomarker field has focused on blood-based biomarkers, which are widely used to predict therapeutic success regarding underlying pathophysiological mechanism, such as inflammation, fibrosis, endothelial damage. This review provides an update of the role of clinically relevant biomarkers in AF, with particular focus on AF rhythm outcomes.

Rhythm outcomes after catheter ablation of atrial fibrillation

Atrial fibrillation (AF) occurs as the result of numerous complex physiological processes in the atria leading to AF promotion and maintenance. Improved diagnostic techniques have identified various biomarkers which may play an important role in the prediction of AF related outcomes (cardio- and cerebrovascular events, as well as mortality and rhythm outcomes). Biomarkers refer to biological markers and biomarkers in blood, urine as well as imaging marker (eg, dimensions (left atrial diameter and volume), anatomical features (left appendage and pulmonary vein anatomy), and physiological pattern (LAA flow velocity)) may play important role(s) as clinically important indices in relation to outcomes after different therapeutic strategies. However, the main domain in the biomarker field has focused on blood-based biomarkers, which are widely used to predict therapeutic success regarding underlying pathophysiological mechanism, such as inflammation, fibrosis, endothelial damage. This review provides an update of the role of clinically relevant biomarkers in AF, with particular focus on AF rhythm outcomes.Atrial fibrillation (AF) occurs as the result of numerous complex physiological processes in the atria leading to AF promotion and maintenance. Improved diagnostic techniques have identified various biomarkers which may play an important role in the prediction of AF related outcomes (cardio- and cerebrovascular events, as well as mortality and rhythm outcomes). Biomarkers refer to ‘biological markers’ and biomarkers in blood, urine as well as imaging marker (eg, dimensions (left atrial diameter and volume), anatomical features (left appendage and pulmonary vein anatomy), and physiological pattern (LAA flow velocity)) may play important role(s) as clinically important indices in relation to outcomes after different therapeutic strategies. However, the main domain in the biomarker field has focused on blood-based biomarkers, which are widely used to predict therapeutic success regarding underlying pathophysiological mechanism, such as inflammation, fibrosis, endothelial damage. This review provides an update of the role of clinically relevant biomarkers in AF, with particular focus on AF rhythm outcomes.

Reduction of stroke and mortality in patients with atrial fibrillation by catheter ablation? Finally, tackling the hard endpoints.

This editorial refers to ‘Successful catheter ablation reduces the risk of cardiovascular events in atrial fibrillation patients with CHA2DS2-VASc risk score of 1 and higher’ by Y.-J. Lin et al. , on page 676 nn‘Will catheter ablation of atrial fibrillation help me live longer and protect me against stroke?’ patients with this arrhythmia quite frequently ask when the pros and cons as well as alternatives of this approach are being discussed.nnWe are living in an era where catheter ablation is an increasingly used treatment for atrial fibrillation (AF).1 In general, catheter ablation should be considered for patients with AF who remain symptomatic despite optimal medical therapy, including rate and rhythm control. Whether to undertake an ablation procedure in a symptomatic patient should take into account the following: (i) the stage of atrial disease (i.e. AF type, left atrial size, AF history), (ii) the presence and severity of underlying cardiovascular disease, (iii) potential treatment alternatives (antiarrhythmic drugs, rate control), and (iv) patients values and preference. According to the 2012 focused update of the ESC Guidelines on management of AF, ablation should even be considered as a first-line therapy in patients with symptomatic, AF and no or minimal heart disease AF.2 Moreover, ablation as adjunct therapy in patients with AF and heart failure treatment is on the horizon.3nnWhat can the patient expect from this procedure? On the one hand, ablation is clearly superior to antiarrhythmic drug therapy with respect to freedom from recurrent AF, which can be achieved in 65–85% patients undergoing ablation, depending on patient characteristics, ablation approaches, and the duration of follow-up.1,3 Consequently, AF-related symptoms are reduced and quality of life as well as functional status are improved. On the other hand, there are severe, potentially life-threatening complications related to this invasive treatment, …