Leonard Bergau

Left atrial volumetry from routine diagnostic work up prior to pulmonary vein ablation is a good predictor of freedom from atrial fibrillation

AIMS This study aimed to identify whether left atrial (LA) volume assessed by multidetector computed tomography (MDCT) is related to the long-term success of pulmonary vein ablation (PVA). MDCT is used to guide PVA for the treatment of atrial fibrillation (AF). MDCT permits accurate sizing of LA dimensions. METHODS AND RESULTS We analysed data from 368 ablation procedures of 279 consecutive patients referred for PVA due to drug-refractory symptomatic AF (age 62 ± 10; 58% men; 71% paroxysmal AF). Prior to the procedure, all patients underwent ECG-gated 64-MDCT scan for assessment of LA and PV anatomy, LA thrombus evaluation, LA volume estimation, and electroanatomical mapping integration. Within a mean follow-up of 356 ± 128 days, 64% of the patients maintained sinus rhythm after the initial ablation, and 84% when including repeat PVA. LA diameter (P = 0.004), LA volume (P = 0.002), and type of AF (P = 0.001) were independent predictors of AF recurrence in univariate analysis. There was a relatively low correlation between the echocardiographic LA diameter and LA volume from MDCT (P = 0.01, r = 0.5). In multivariate analysis, paroxysmal AF (P < 0.006) and LA volume below the median value of 106 mL (P = 0.042) were significantly associated with the success of PVA, whereas LA diameter was not (P = 0.245). Analysing receiver-operator characteristics, the area under the curve for LA volume was 0.73 (P = 0.001) compared with 0.60 (P = 0.09) for LA diameter from echocardiography. CONCLUSION LA volume assessed by MDCT is a better predictor of AF recurrence after PVA than echocardiograpic LA diameter and can be derived from the pre-procedural imaging data set.

Prevalence of noncardiac findings in computed tomography angiography before transcatheter aortic valve replacement

OBJECTIVE This study sought to determine the prevalence of significant and nonsignificant noncardiac findings in patients undergoing preprocedural dual-source CT (DSCT) before transcatheter aortic valve implantation (TAVI). METHODS Patients (n = 204; aged, 80.5 ± 5.1 years; 106 men) underwent preprocedural DSCT of the thoracoabdominal aorta and the pelvic arterial vessels. Noncardiac findings were recorded and categorized as nonsignificant (group A), incidental findings requiring follow-up examinations (group B), and significant findings with a demand for clinical treatment (group C). RESULTS In 60 of 204 DSCT examinations (29.4%) no noncardiac findings were observed. Of the remaining 144 examinations (70.6%), 260 had noncardiac findings; 35 of 204 patients (17.1%) had a total of 37 clinically significant noncardiac findings. Eight malignancies were detected; 5 of them were incidentally diagnosed on DSCT and changed patient management. A total of 223 nonsignificant findings were observed in 116 of 204 patients (56.9%; group A), the most frequent findings were pleural effusions or colorectal diverticulosis. The prevalence of incidental and significant findings on DSCT before TAVI increased with patient age (r(2) = 0.69; P = .01). CONCLUSION Significant noncardiac findings are common in patients referred to routine preprocedural DSCT for planning TAVI (17.1%).

Pulmonary vein anatomy predicts freedom from atrial fibrillation using remote magnetic navigation for circumferential pulmonary vein ablation

AIMS Multidetector computed tomography (MDCT) is frequently used to guide circumferential pulmonary vein ablation (PVA) for treatment of atrial fibrillation (AF) as it offers accurate visualization of the left atrial (LA) and pulmonary vein (PV) anatomy. This study aimed to identify if PV anatomy is associated with outcomes following PVA using remote magnetic navigation (RMN). METHODS AND RESULTS We analysed data from 138 consecutive patients and 146 ablation procedures referred for PVA due to drug-refractory symptomatic AF (age 63 ± 11 years; 57% men; 69% paroxysmal AF). The RMN using the stereotaxis system and open-irrigated 3.5 mm ablation catheters was used in all procedures. Prior to PVA, all patients underwent electrocardiogram-gated 64-MDCT for assessment of LA dimensions, PV anatomy, and electro-anatomical image integration during the procedure. Regular PV anatomy was found in 68%, a common left PV ostium was detected in 26%, and variant anatomy of the right PVs was detected in 6%. After a mean follow-up of 337 ± 102 days, 63% of the patients maintained sinus rhythm after the initial ablation, and 83% when including repeat PVA. Although acutely successful PV isolation did not differ between anatomical subgroups (regular 3.5 ± 0.8 vs. variant 3.2 ± 1.3; P = 0.31), AF recurrence was significantly higher in patients with non-regular PV anatomy (P = 0.04, hazard ratio 1.72). Pulmonary vein anatomy did not influence complication rates. CONCLUSION Pulmonary vein anatomy assessed by MDCT is a good predictor of AF recurrence after PVA using RMN.

Sex difference in appropriate shocks but not mortality during long-term follow-up in patients with implantable cardioverter-defibrillators

Abstract Aims Implantable cardioverter-defibrillators (ICDs) have been shown to improve survival, although a considerable number of patients never receive therapy. Implantable cardioverter-defibrillators are routinely implanted regardless of sex. There is continuing controversy whether major outcomes differ between men and women. Methods and results In this retrospective single-centre study, 1151 consecutive patients (19% women) undergoing ICD implantation between 1998 and 2010 were followed for mortality and first appropriate ICD shock over 4.9 ± 2.7 years. Sex-related differences were investigated using multivariable Cox models adjusting for potential confounders. During follow-up, 318 patients died, a rate of 5.9% per year among men and 4.6% among women (uncorrected P = 0.08); 266 patients received a first appropriate ICD shock (6.3% per year among men vs. 3.6% among women, P = 0.002). After multivariate correction, independent predictors of all-cause mortality were age (hazard ratio, HR = 1.04 per year of age, 95% confidence interval (CI) [1.03–1.06], P < 0.001), left ventricular ejection fraction (HR = 0.98 per %, 95% CI [0.97–1.00], P = 0.025), renal function (HR = 0.99 per mL/min/1.73 m2, 95% CI [0.99–1.00], P = 0.009), use of diuretics (HR = 1.81, 95% CI [1.29–2.54], P = 0.0023), peripheral arterial disease (HR = 2.21, 95% CI [1.62–3.00], P < 0.001), and chronic obstructive pulmonary disease (HR = 1.48, 95% CI [1.13–1.94], P = 0.029), but not sex. Female sex (HR = 0.51, 95% CI [0.33–0.81], P = 0.013), older age (HR = 0.98, 95% CI [0.97–0.99], P < 0.001), and primary prophylactic ICD indication (HR = 0.69, 95% CI [0.52–0.93], P = 0.043) were independent predictors for less appropriate shocks. Conclusion Women receive 50% less appropriate shocks than men having similar mortality in this large single-centre population. These data may pertain to individually improved selection of defibrillator candidates using risk factors, e.g. sex as demonstrated in this study.

Gender Differences in Appropriate Shocks and Mortality among Patients with Primary Prophylactic Implantable Cardioverter-Defibrillators: Systematic Review and Meta-Analysis.

Background Some but not all prior studies have shown that women receiving a primary prophylactic implantable cardioverter defibrillator (ICD) have a lower risk of death and appropriate shocks than men. Purpose To evaluate the effect of gender on the risk of appropriate shock, all-cause mortality and inappropriate shock in contemporary studies of patients receiving a primary prophylactic ICD. Data Source PubMed, LIVIVO, Cochrane CENTRAL between 2010 and 2016. Study Selection Studies providing at least 1 gender-specific risk estimate for the outcomes of interest. Data Extraction Abstracts were screened independently for potentially eligible studies for inclusion. Thereby each abstract was reviewed by at least two authors. Data Synthesis Out of 680 abstracts retained by our search strategy, 20 studies including 46’657 patients had gender-specific information on at least one of the relevant endpoints. Mean age across the individual studies varied between 58 and 69 years. The proportion of women enrolled ranged from 10% to 30%. Across 6 available studies, women had a significantly lower risk of first appropriate shock compared with men (pooled multivariable adjusted hazard ratio 0.62 (95% CI [0.44; 0.88]). Across 14 studies reporting multivariable adjusted gender-specific hazard ratio estimates for all-cause mortality, women had a lower risk of death than men (pooled hazard ratio 0.75 (95% CI [0.66; 0.86]). There was no statistically significant difference for the incidence of first inappropriate shocks (3 studies, pooled hazard ratio 0.99 (95% CI [0.56; 1.73]). Limitations Individual patient data were not available for most studies. Conclusion In this large contemporary meta-analysis, women had a significantly lower risk of appropriate shocks and death than men, but a similar risk of inappropriate shocks. These data may help to select patients who benefit from primary prophylactic ICD implantation.

Vascular and extravascular findings on magnetic resonance angiography of the thoracic aorta and the origin of the great vessels

To investigate the presence of relevant vascular and incidental extravascular findings in patients undergoing magnetic resonance angiography (MRA) of the thoracic aorta and origin of the great vessels.

Measurement of Left Atrial Pressure is a Good Predictor of Freedom From Atrial Fibrillation

Background It is suggested that an elevated left atrial pressure (LAP) promotes ectopic beats emanating in the pulmonary veins (PVs) and that LAP might be a marker for structural remodeling. This study aimed to identify if the quantification of LAP correlates with structural changes of the LA and may therefore be associated with outcomes following pulmonary vein isolation (PVI). Methods We analysed data from 120 patients, referred to PVI due to drug-refractory atrial fibrillation (AF) (age 63±8; 57% men). The maximum (mLAP) and mean LAP (meLAP) were measured after transseptal puncture. Results and Conclusions Within a mean follow-up of 303±95 days, 60% of the patients maintained in sinus rhythm after the initial procedure and 78% after repeated PVI. Performing univariate Cox-regression analysis, type of AF, LA-volume (LAV), mLAP and the meLAP were significant predictors of recurrence after PVI (p=0.03; p=0.001; p=0.01). In multivariate analysis mLAP>18mmHg, LAV>100 ml and the presence of persistent AF were significant predictors (p=0.001; p=0.019; p=0.017). The mLAP >18 mmHg was associated with a hazard ratio of 3.8. Analyzing receiver-operator characteristics, the area under the curve for mLAP was 0.75 (p<0.01). mLAP >18 mmHg predicts recurrence with a sensitivity of 77 % and specificity of 60 %. There was a linear correlation between the LAV from MDCT and mLAP (p = 0.01, R2 = 0.61). The mLAP measured invasively displays a significant predictor for AF recurrence after PVI. There is a good correlation between LAP and LAV and both factors may be useful to quantify LA remodeling.

ICD risk stratification studies – EU-CERT-ICD and the European perspective

BACKGROUND AND RATIONALE In patients with ischemic or non-ischemic cardiomyopathy and impaired left ventricular ejection fraction, treatment with implantable cardioverter-defibrillator (ICD) has been shown to improve survival and guidelines recommend their use for primary prevention of sudden cardiac death. Experts disagree regarding the validity of decade-old trial results as the basis for this recommendation, therefore, reconsideration of prophylactic ICD treatment is needed. EU-CERT-ICD, DANISH-ICD AND DO-IT In order to update the evidence on prophylactic ICD treatment, several prospective studies are underway in Europe. The prospective EU-CERT-ICD cohort study (NCT 02064192) is enrolling 2500 patients and compares patients undergoing first ICD implantation with controls with an earlier clinical decision to go without ICD implantation strictly unrelated to the study. The DANISH ICD study (NCT 00542945) has randomized 1000 patients with dilated cardiomyopathy and an LVEF ≤35% (1:1 ICD implantation vs. control). The prospective DO-IT multicenter registry will include 1500 ICD patients in multiple Dutch high-volume implanting centers. Due to the widespread use of ICD therapy, new randomized trials seem not straightforward to envisage in many countries. CONCLUSION The above described ICD studies will provide additional evidence regarding the effectiveness of primary prophylactic ICDs in Europe and may have an impact on ICD treatment guidelines. They could also help to design randomized trials in low risk patients.

Sex differences in ICD benefit

BACKGROUND Implantable cardioverter defibrillators (ICD) have been demonstrated to improve survival, but a considerable number of patients never receive appropriate therapy. The influence of sex on ICD effectiveness in primary prophylactic ICD therapy is unclear. SUMMARY Until now, guideline recommendations are equal for men and women, yet only an average of 20% of enrolled patients in large randomized ICD studies were women. Epidemiological data from the Framingham Heart Study exhibit lower incidences of SCD in women (≈50%). This difference is in only in part owed to less severe underlying cardiac disease or comorbidities but it persists after correction of confounding factors. Several of the large randomized studies have conducted gender substudies. In MADIT-II, the survival benefit for women was similar as for men, although the risk of appropriate ICD therapy was lower for women. In SCD-HeFT and DEFINITE, the survival benefits for women were less compared to men, or not existent. Trends were contradictingly summarized by two meta-analyses. By this important post-hoc research, important hypotheses for prospective work in the ICD subgroup of women are generated. At the same time, it is undisputed that the complication rate of ICD implantations is higher in women. The largest ICD registry to date Ontario (Canada) confirms the lower appropriate shock rate in women but found no differences in total mortality. CONCLUSIONS Further subgroup analyses of large ICD cohorts by sex are needed, as well as studies investigating the influence of sex on ICD treatment--and potentially ICD indication--prospectively.

Differential multivariable risk prediction of appropriate shock versus competing mortality - A prospective cohort study to estimate benefits from ICD therapy

BACKGROUND AND OBJECTIVE We prospectively investigated combinations of risk stratifiers including multiple EP diagnostics in a cohort study of ICD patients. METHODS For 672 enrolled patients, we collected history, LVEF, EP study and T-wave alternans testing, 24-h Holter, NT-proBNP, and the eGFR. All-cause mortality and first appropriate ICD shock were predefined endpoints. RESULTS The 635 patients included in the final analyses were 63 ± 13 years old, 81% were male, LVEF averaged 40 ± 14%, 20% were inducible at EP study, 63% had a primary prophylactic ICD. During follow-up over 4.3 ± 1.5 years, 108 patients died (4.0% per year), and appropriate shock therapy occurred in n = 96 (3.9% per year). In multivariate regression, age (p < 0.001), LVEF (p < 0.001), NYHA functional class (p = 0.007), eGFR (p = 0.024), a history of atrial fibrillation (p = 0.011), and NT-pro-BNP (p = 0.002) were predictors of mortality. LVEF (p = 0.002), inducibility at EP study (p = 0.007), and secondary prophylaxis (p = 0.002) were identified as independent predictors of appropriate shocks. A high annualized risk of shocks of about 10% per year was prevalent in the upper quintile of the shock score. In contrast, a low annual risk of shocks (1.8% per year) was found in the lower two quintiles of the shock score. The lower two quintiles of the mortality score featured an annual mortality <0.6%. CONCLUSIONS In a prospective ICD patient cohort, a very good approximation of mortality versus arrhythmic risk was possible using a multivariable diagnostic strategy. EP stimulation is the best test to assess risk of arrhythmias resulting in ICD shocks.