Seweryn Nowak

Comparison of pulmonary veins anatomy in patients with and without atrial fibrillation: analysis by multislice tomography.

UNLABELLED A possible role of anomalies in number and insertion of pulmonary veins (PV) in initiating atrial fibrillation (AF) has been suggested. It has been shown as well that changes in anatomy of PVs such as enlargement may have an effect on arrhythmogenesis. The aim of the study was to compare anatomy of the left atrium (LA) and PVs in patients with AF and control subjects. METHODS Eighty two patients were evaluated with 64-slice computed tomography (MSCT). Fifty one of them were referred to catheter ablation with history of highly symptomatic AF--AF(+) group. Thirty one control subjects had no history of AF and were referred to MSCT for noninvasive evaluation of different pathologies which finally were excluded--AF(-) group. Study groups did not differ in regard to age, sex, presence of hypertension and left ventricular systolic function. Diameters of PV ostia were measured in anterior-posterior (AP) and superior-inferior (SI) directions. Venous ostium index was calculated as a ratio between these measurements. RESULTS The diameter of LA was higher in AF(+) patients than in the AF(-) patients (39±6 mm vs. 35±4 mm, p<0.005). In 68.6% of AF(+) patients and in 83.9% of AF(-) patients the anatomical pattern was typical with two right and two left PVs. Additional PVs were detected in 6 patients, only in AF(+) group (p<0.05). Common ostia were more frequently found in AF(+) subjects (37.2% vs. 19.3, p=0,08), mainly left-sided. In AF(+) group mean SI diameters of both-sided superior PVs and left inferior veins were larger. All AP diameters except for right inferior PVs were also larger in AF(+) group than in control cases. CONCLUSIONS Variations in the PVs anatomy are more common and diameters of ostial portions of the veins are larger in AF patients than in control subjects. These findings suggest that further studies on the role of structural abnormalities of PVs in arrhythmogenesis are needed.

CHA2DS2-Vasc score, age and body mass index as the main risk factors of hyperintense brain lesions in asymptomatic patients with paroxysmal non-valvular atrial fibrillation

BACKGROUND The aim was to assess the occurrence, severity and risk factors for silent white matter hyperintensities (WMH) in brain magnetic resonance imaging (MRI) in patients with atrial fibrillation (AF) and to determine the potential relationship between WHM and cognitive decline. METHODS Seventy-four patients with paroxysmal non-valvular AF were enrolled (age 59 (IQR 50-63)years, males 45/61%). All patients were on adequate warfarin treatment before inclusion and had no history of stroke or TIA. The presence and severity of brain WMH were classified according to the Fazekas scale, while general neurocognitive function was assessed using the Mini-Mental State Examination (MMSE). RESULTS WMH were found in 51 patients (67.6%; age: 59±7.9years; males: 29/58%). CHADS2-VASc score (OR for 1 point 2.18; 95% CI=1.3-3.65; p=0.003), age (OR for 1year 1.11; 95% CI=1.04-1.18; p=0.001) and BMI (OR for 1kg/m(2) 1.23; 95% CI=1.04-1.45; p=0.017) were independent factors of any brain lesions. A positive correlation between Fazekas scale score and CHA2DS2-VASc score was shown in the entire group (Gamma 0.48; p<0.001). In the group with brain lesions, AF time (p=0.02) and LVEDD (p=0.03) significantly determined the Fazekas scale score (lesions severity). There were no differences in the MMSE score between patients with and without WMH (median: 28 (IQR 27-29) vs 29 (IQR 27.5-30); p=0.2). CONCLUSIONS Both the presence and severity of brain WMH are related to the CHADS2-VASc score and are not connected with cognitive impairment in this population. Age, BMI, AF time and the indices of heart remodeling constitute important factors influencing brain lesions.

Differentiation of arrhythmia originating from the right or left ventricular outflow tract based on the QRS morphology of premature ventricular beats and duration of repolarisation

BACKGROUND Premature ventricular beats (PVBs) and monomorphic ventricular tachycardia originating from the right ventricular outflow tract (RVOT) are the most frequent forms of idiopathic ventricular arrhythmias, but arrhythmia originating from the left ventricular outflow tract (LVOT) may be found in about 10% of these patients. AIM To compare electrocardiographic (ECG) patterns and duration of repolarisation after PVBs originating from the left and right superior part of the interventricular septum which were successfully treated with radiofrequency catheter ablation. METHODS We studied 62 patients who did not receive antiarrhythmic drug treatment before ablation, including 50 patients with RVOT arrhythmia (21 males, mean age 42 ± 14 years, left ventricular ejection fraction [LVEF] 61 ± 6%) and 12 patients with LVOT arrhythmia (3 males, mean age 41 ± 17 years, LVEF 59 ± 9%). Pre-ablation 24-h Holter ECG recordings were analysed for the total number of PVBs. In addition, we evaluated ectopic beat QRS duration, prematurity index and duration of repolarisation (QT interval, JT interval and TpeakTend values uncorrected for the heart rate) based on ten random daytime PVBs during a period of stable sinus rhythm at a rate of 60-70 bpm. RESULTS The study groups did not differ by age, LVEF, heart rate and the number of PVBs. RVOT arrhythmia was characterised by a lower prematurity index (0.59 ± 0.11 vs. 0.72 ± 0.09, p = 0.001) and a lower R/S ratio in leads V1-V3 (p < 0.01 for each lead). QRS duration of right-sided PVBs was shorter compared to that of left-sided PVBs (147 ± 13 vs. 166 ± 13 ms, p = 0.002), QT and JT intervals were similar (QT: 422 ± 32 vs. 429 ± 27 ms, p = 0.35; JT: 272 ± 27 vs. 266 ± 27 ms, p = 0.31), and TpeakTend was shorter in RVOT arrhythmia (100 ± 10 vs. 110 ± 6 ms, p = 0.01). Combination of R > S in lead V3 and TpeakTend-PVB > 110 ms identified LVOT arrhythmia with a sensitivity of 75% and specificity of 96%. CONCLUSIONS Ventricular arrhythmias originating from the left or right superior part of the interventricular septum are not only characterised by different ECG patterns of ventricular ectopic beats but also show significant differences in the repolarisation phase.

Lower soluble Klotho and higher fibroblast growth factor 23 serum levels are associated with episodes of atrial fibrillation

Aims The proarrhythmic effect of fibroblast growth factor 23 (FGF23) was observed in patients with end stage kidney disease (ESKD). However, there is no data on the role of FGF23 and soluble Klotho (sKlotho) in the pathogenesis of atrial fibrillation (AF) beyond ESKD. The aim of the study was to assess the peripheral vein and left atrial (LA) serum levels of FGF23 and sKlotho along with calcium‐phosphates parameters in patients with AF undergoing percutaneous radiofrequency pulmonary vein isolation (PVI). Methods and results Sixty‐nine consecutive patients (mean age: 55.8 ± 9.7 years, F/M: 26/43, CHA2DS2‐Vasc: 1.7 ± 1.1) with paroxysmal/persistent AF undergoing PVI were included into the study. Blood samples were taken during PVI – baseline from the peripheral vein, then from the LA immediately after a septal puncture. Results There were significant differences in the concentrations of peripheral and LA serum sKlotho, intact FGF23 (iFGF23), calcium and phosphates; peripheral FGF23, calcium and phosphates levels were significantly higher, and sKlotho levels were significantly lower than the LA concentrations. Serum sKlotho levels correlated with the CHADS2‐VASc score (r = 0.254, p = 0.034) and glucose level (r = 0.300, p = 0.005). Serum sKlotho gradient (LA – peripheral vein) correlated with the baseline AF burden in the Holter monitoring (r = −0.389, p = 0.003). PVI efficacy was confirmed in 52 (75%) patients. There was a significant difference in the iFGF23 gradient between patients with AF and without AF (80.3 vs. −47.6 pg/ml, p = 0.009) in the six‐month follow‐up. A receiver operating characteristic (ROC) analysis revealed that an iFGF23 gradient >28.7 pg/ml (AUC = 0.742, p = 0.002) was a predictor for AF recurrence. Conclusions There is a gradient between the LA and peripheral vein in the markers of calcium‐phosphate metabolism in patients undergoing PVI. Lower sKlotho and higher iFGF23 serum levels are associated with episodes of AF. Serum iFGF23 gradient is a potent predictor for the recurrence of AF. HighlightsFGF23 and soluble Klotho play a role in the pathogenesis of atrial fibrillation.Gradient in the concentrations of peripheral and atrial serum sKlotho and FGF23.Serum sKlotho gradient correlated with the AF burden in the Holter monitoring.iFGF23 gradient >28.7 pg/ml was a predictor for atrial fibrillation recurrence.Lower sKlotho and higher iFGF23 serum levels are associated with episodes of AF.

Quality of life in patients with paroxysmal atrial fibrillation after circumferential pulmonary vein ablation.

BACKGROUND Atrial fibrillation (AF) is the most common arrhythmia and is associated with a deterioration of quality of life (QoL). Catheter ablation is a therapeutic strategy for some patients with AF. The effectiveness of pulmonary vein isolation is still under assessment. AIM To assess the long-term influence of circumferential pulmonary vein ablation (CPVA) on QoL in patients with AF. METHODS The study population consisted of 33 patients (26 males, age 54.2 ± 9 years) with highly symptomatic (EHRA II-III) drug refractory paroxysmal AF, who underwent CPVA. A clinical examination, electrocardiogram (ECG), and Holter ECG were performed before and during a one-year follow-up. The SF-36 Medical Outcomes Survey Short-Form QoL questionnaire, scored on a 0-100 scale for each of eight domains: bodily pain (BP), general health (GH), mental health (MH), physical functioning (PF), role-emotional (RE), role-physical (RP), social functioning (SF), and vitality (V), was collected before and one year after CPVA. RESULTS In the one-year follow-up 27 (82%) patients were free of AF. EHRA symptoms were improved one-year after CPVA regardless of CPVA efficacy. After the follow-up the SF-36 questionnaire results improved significantly in all of the subscales in patients without a recurrence of AF after CPVA. In subjects with a recurrence of AF, all of the subscales did not indicate any statistically significant differences. There was an association between the CPVA and the following QoL domains: GH (p = 0.018), PF (p = 0.042), and V (p = 0.041). The highest values of the GH and V domains were found in the non-recurrence patients one year after CPVA. CONCLUSIONS CPVA results in the clinical improvement of patients with symptomatic AF regardless of the final arrhythmia termination. Patients after successful CPVA experienced a significant improvement in all of the subscales of the QoL.