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Annals of Cardiac Anaesthesia 2015Given the high incidence of atrial fibrillation (AF) in the surgical population and the associated morbidity, physicians managing these complicated patients in the... (Review)
Review
Given the high incidence of atrial fibrillation (AF) in the surgical population and the associated morbidity, physicians managing these complicated patients in the perioperative period need to be aware of the new and emerging trends in its therapy. The cornerstones of AF management have always been rate/rhythm control as well as anticoagulation. Restoration of sinus rhythm remains the fundamental philosophy as it maintains the atrial contribution to cardiac output and improves ventricular function. The recent years have seen a dramatic increase in the number of randomized AF trials that have made significant advances to our understanding of both pharmacologic and procedural management, from the introduction of the new generation of oral anticoagulants (NOAC's) to catheter approaches for AF ablation. This paper will summarize the newest data that will affect the perioperative management of these patients.
Topics: Anti-Arrhythmia Agents; Anticoagulants; Atrial Fibrillation; Catheter Ablation; Electric Countershock; Fibrinolytic Agents; Humans; Perioperative Care
PubMed: 26440243
DOI: 10.4103/0971-9784.166466 -
Current Cardiology Reviews 2020Frequent premature ventricular contractions (PVC) can result in PVCinduced cardiomyopathy (PVC-iCMP), leading to reduced Left Ventricular Ejection Fraction (LVEF) that...
BACKGROUND
Frequent premature ventricular contractions (PVC) can result in PVCinduced cardiomyopathy (PVC-iCMP), leading to reduced Left Ventricular Ejection Fraction (LVEF) that can be improved by radiofrequency catheter ablation (RFCA). We performed a systematic review to determine the variables predicting LVEF improvement after RFCA in PVCiCMP.
METHODS
We developed a "population, intervention, outcome and predictive factors" framework and searched MEDLINE, Embase, Cochrane Library, Cochrane Collaboration and Cochrane Database of Systematic Reviews (CDSR) for full-text, peer-reviewed publications. These publications addressing predictive factors of LVEF improvement showed ≥5% improvement only if deemed significant by the respective study, ≥10% or ≥ 50% after RFCA ablation in patients with PVCiCMP with no type/date/language limitation until the end of 2017.
RESULTS
Our initial search yielded 2226 titles, 1519 of which remained after removing the duplicates. Finally, 11 articles - 2 cohorts, 7 quasi-experimental studies, 1 case-control and 1 metaanalysis- were included. Sustained successful ablation, higher baseline PVC burden, LVEF, QRS duration, post-PVC systolic blood pressure rise and post-PVC pulse pressure change, the absence of an underlying cardiomyopathy, younger age, and variability of the frequency of PVCs during the day and lower left ventricular end-diastolic diameter (LVEDD) have been suggested as predictive factors for LVEF improvement in patients with PVC-iCMP.
CONCLUSION
The mentioned factors may all be useful to identify PVC-iCMP patients who would benefit from RFCA, although the evidence is not yet strong enough.
Topics: Cardiomyopathies; Catheter Ablation; Female; Humans; Male; Treatment Outcome; Ventricular Function, Left; Ventricular Premature Complexes
PubMed: 31288727
DOI: 10.2174/1573403X15666190710095248 -
Frontiers in Cardiovascular Medicine 2022Catheter ablation (CA) is a fundamental therapeutic option for the treatment of recurrent ventricular arrhythmias. Notwithstanding the tremendous improvements in the...
Catheter ablation (CA) is a fundamental therapeutic option for the treatment of recurrent ventricular arrhythmias. Notwithstanding the tremendous improvements in the available technology and the increasing amount of evidence in support of CA, in some patients the procedure fails, or is absolutely contraindicated due to technical or clinical issues. In these cases, the clinical management of patients is highly challenging, and mainly involves antiarrhythmic drugs escalation. Over the last 5 years, stereotactic arrhythmia radioablation (STAR) has been introduced into clinical practice, with several small studies reporting favorable arrhythmia-free outcomes, without severe side effects at a short to mid-term follow-up. In the present systematic review, we provide an overview of the available studies on stereotactic arrhythmia radioablation, by describing the potential indications and technical aspects of this promising therapy.
PubMed: 36072869
DOI: 10.3389/fcvm.2022.870001 -
BMC Cardiovascular Disorders Jan 2019Previous randomized controlled trials (RCT)s showed similar outcomes in patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF)... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Previous randomized controlled trials (RCT)s showed similar outcomes in patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) treated with anti-arrhythmic drugs (AAD) compared to rate control therapy. We sought to evaluate whether catheter ablation is superior to medical therapy in patients with AF and HFrEF.
METHODS
We searched electronic databases for all RCTs that compared catheter ablation and medical therapy (with or without use of AAD). We used random-effects models to summarize the studies. The primary end-point was all-cause mortality. Secondary outcomes included heart failure-related hospitalizations and change in left ventricular ejection fraction (LVEF).
RESULTS
We retrieved and summarized 7 randomized controlled trials, enrolling 856 patients (429 in the catheter ablation arm and 427 in the medical therapy arm). Compared with medical therapy (including use of AAD), AF catheter ablation was associated with a significant reduction in mortality (risk ratio 0.50; 95% confidence interval [CI]: 0.34 to 0.74; P = 0.0005) and heart failure-related hospitalizations (risk ratio 0.56; 95% CI: 0.44 to 0.71; P < 0.0001). Furthermore, catheter ablation led to significant improvements in LVEF (weighted mean difference, 7.48; 95% CI: 3.71 to 11.26; P < 0.0001).
CONCLUSIONS
Compared to medical therapy, including use of AAD, catheter ablation for AF was associated with a significant reduction in mortality and heart failure-related hospitalizations as well as an improvement in LVEF in patients with HFrEF. Larger trials are needed to confirm whether rhythm control with ablation is superior to rate control in patients with AF and heart failure.
Topics: Anti-Arrhythmia Agents; Atrial Fibrillation; Catheter Ablation; Disease Progression; Heart Failure; Heart Rate; Humans; Randomized Controlled Trials as Topic; Recovery of Function; Risk Factors; Stroke Volume; Treatment Outcome; Ventricular Function, Left
PubMed: 30646857
DOI: 10.1186/s12872-019-0998-2 -
Journal of Interventional Cardiac... Oct 2020Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained... (Meta-Analysis)
Meta-Analysis
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
Topics: Cardiac Electrophysiology; Catheter Ablation; Consensus; Humans; Tachycardia, Ventricular; Ventricular Premature Complexes
PubMed: 31960344
DOI: 10.1007/s10840-019-00664-2 -
Journal of Cardiovascular... Nov 2020The presentation and optimal management of maternal focal atrial tachycardia (AT) during pregnancy are unknown. The objective of this study is to conduct a comprehensive...
INTRODUCTION
The presentation and optimal management of maternal focal atrial tachycardia (AT) during pregnancy are unknown. The objective of this study is to conduct a comprehensive summary of the existing evidence.
METHODS AND RESULTS
A systematic review of all reported cases of maternal focal AT during pregnancy was performed. The primary search queried PubMed using the MeSH terms "supraventricular tachycardia" and "pregnancy." A stepwise ancillary search included article bibliographies, citations listed by the Google internet search engine, and PubMed using the MeSH terms "atrial tachycardia" and "pregnancy." In total, 28 citations that described 32 patients were retrieved. A case from our institution was added. Detailed information was available for 30 patients. Clinical characteristics at presentation included a mean ± standard deviation of 28.3 ± 5.7 years for maternal age and 24.6 ± 7.7 weeks for gestation age. Suspected tachycardia-induced cardiomyopathy was present in 20 of 30 (67%) patients and left ventricular ejection fraction improved in 15 of 15 (100%) patients with follow-up measurements. Medication failure was common. Focal AT resolved spontaneously after delivery in eight of nine (89%) patients treated with only medications. Automaticity was suggested by discrete electrograms at sites of origin and lack of reported inducibility and termination with programmed stimulation in all patients who underwent electrophysiology studies. There were nine cases of successful catheter ablation with zero fluoroscopy since 2010.
CONCLUSIONS
Automaticity is the dominant mechanism for patients with maternal focal AT during pregnancy. Catheter ablation with zero fluoroscopy is an emerging therapy for medically refractory cases.
Topics: Adult; Catheter Ablation; Female; Humans; Pregnancy; Stroke Volume; Tachycardia, Supraventricular; Treatment Outcome; Ventricular Function, Left; Young Adult
PubMed: 32897619
DOI: 10.1111/jce.14738 -
Reviews in Cardiovascular Medicine Sep 2020Several observational studies have shown a survival benefit for patients with atrial fibrillation (AF) who are treated with catheter ablation (CA) rather than medical... (Meta-Analysis)
Meta-Analysis
Several observational studies have shown a survival benefit for patients with atrial fibrillation (AF) who are treated with catheter ablation (CA) rather than medical management (MM). However, data from randomized controlled trials (RCTs) are uncertain. Therefore, we performed a meta-analysis of RCTs that compared the benefits of CA and MM in treatment of AF. We searched the Cochrane Library, PubMed, and EMBASE databases for RCTs that compared AF ablation with MM from the time of database establishment up to January 2020. The risk ratio (RR) with a 95% confidence interval (CI) was used as a measure treatment effect. Twenty-six RCTs that enrolled a total of 5788 patients were included in the meta-analysis. In this meta-analysis, the effect of AF ablation depended on the baseline level of left ventricular ejection fraction (LVEF) in the heart failure (HF) patients. AF ablation appears to be of benefit to patients with a lesser degree of advanced HF and better LVEF by reducing mortality. Meanwhile, this mortality advantage was manifested in long-term follow-up. CA increased the risk for hospitalization when it was used as first-line therapy and decreased the risk when used as second-line therapy. CA reduced recurrence of atrial arrhythmia for different types of AF (paroxysmal or persistent AF) and CA-related complications were non-negligible. There was no convincing evidence for a reduction in long-term stroke risk after AF ablation, and additional high quality RCTs are needed to address that issue.
Topics: Adult; Aged; Anti-Arrhythmia Agents; Atrial Fibrillation; Catheter Ablation; Female; Heart Rate; Humans; Male; Middle Aged; Randomized Controlled Trials as Topic; Recurrence; Risk Assessment; Risk Factors; Stroke; Time Factors; Treatment Outcome
PubMed: 33070546
DOI: 10.31083/j.rcm.2020.03.60 -
Circulation Aug 2019It is unclear whether physiologic pacing by either cardiac biventricular pacing (BiVP) or His bundle pacing (HisBP) may prevent adverse structural and functional... (Meta-Analysis)
Meta-Analysis
Impact of Physiologic Pacing Versus Right Ventricular Pacing Among Patients With Left Ventricular Ejection Fraction Greater Than 35%: A Systematic Review for the 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the...
BACKGROUND
It is unclear whether physiologic pacing by either cardiac biventricular pacing (BiVP) or His bundle pacing (HisBP) may prevent adverse structural and functional consequences known to occur among some patients who receive right ventricular pacing (RVP).
AIM
Our analysis sought to review existing literature to determine if BiVP and/or HisBP might prevent adverse remodeling and be associated with structural, functional, and clinical advantages compared with RVP among patients without severe left ventricular dysfunction (>35%) who required permanent pacing because of heart block.
METHODS
A literature search was conducted using MEDLINE (through PubMed) and Embase to identify randomized trials and observational studies comparing the effects of BiVP or HisBP versus RVP on measurements of left ventricular dimensions, left ventricular ejection fraction (LVEF), heart failure functional classification, quality of life, 6-minute walk, hospitalizations, and mortality. Data from studies that met the appropriate population, intervention, comparator, and outcomes of interest were abstracted for meta-analysis. Studies that reported pooled outcomes among patients with LVEF both above and below 35% could not be included in the meta-analysis because of strict relationships with industry procedures that preclude retrieval of industry-retained unpublished data on the subset of patients with preserved left ventricular function.
RESULTS
Evidence from 8 studies, including a total of 679 patients meeting the prespecified criteria for inclusion, was identified. Results were compared for BiVP versus RVP, HisBP versus RVP, and BiVP+HisBP versus RVP. Among patients who received physiologic pacing with either BiVP or HisBP, the LV end-diastolic and end-systolic volumes were significantly lower (mean duration of follow-up: 1.64 years; -2.77 mL [95% CI -4.37 to -1.1 mL]; P=0.001; and -7.09 mL [95% CI -11.27 to -2.91; P=0.0009) and LVEF remained preserved or increased (mean duration of follow-up: 1.57 years; 5.328% [95% CI: 2.86%-7.8%; P<0.0001). Data on clinical impact such as functional status and quality of life were not definitive. Data on hospitalizations were unavailable. There was no effect on mortality. Several studies stratified results by LVEF and found that patients with LVEF >35% but ≤52% were more likely to receive benefit from physiologic pacing. Patients with chronic atrial fibrillation who underwent atrioventricular node ablation and pacemaker implant demonstrated clear improvement in LVEF with BiVP or HisBP versus RVP.
CONCLUSION
Among patients with LVEF >35%, the LVEF remained preserved or increased with either BiVP or HisBP compared with RVP. However, patient-centered clinical outcome improvement appears to be limited primarily to patients who have chronic atrial fibrillation with rapid ventricular response rates and have undergone atrioventricular node ablation.
Topics: Atrial Fibrillation; Bradycardia; Cardiac Conduction System Disease; Cardiac Pacing, Artificial; Humans; Practice Guidelines as Topic; Quality of Life; Stroke Volume; Ventricular Function, Left
PubMed: 30586773
DOI: 10.1161/CIR.0000000000000629 -
Journal of the American College of... Aug 2019It is unclear whether physiologic pacing by either cardiac biventricular pacing (BiVP) or His bundle pacing (HisBP) may prevent adverse structural and functional... (Comparative Study)
Comparative Study
Impact of Physiologic Pacing Versus Right Ventricular Pacing Among Patients With Left Ventricular Ejection Fraction Greater Than 35%: A Systematic Review for the 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the...
BACKGROUND
It is unclear whether physiologic pacing by either cardiac biventricular pacing (BiVP) or His bundle pacing (HisBP) may prevent adverse structural and functional consequences known to occur among some patients who receive right ventricular pacing (RVP).
AIM
Our analysis sought to review existing literature to determine if BiVP and/or HisBP might prevent adverse remodeling and be associated with structural, functional, and clinical advantages compared with RVP among patients without severe left ventricular dysfunction (>35%) who required permanent pacing because of heart block.
METHODS
A literature search was conducted using MEDLINE (through PubMed) and Embase to identify randomized trials and observational studies comparing the effects of BiVP or HisBP versus RVP on measurements of left ventricular dimensions, left ventricular ejection fraction (LVEF), heart failure functional classification, quality of life, 6-minute walk, hospitalizations, and mortality. Data from studies that met the appropriate population, intervention, comparator, and outcomes of interest were abstracted for meta-analysis. Studies that reported pooled outcomes among patients with LVEF both above and below 35% could not be included in the meta-analysis because of strict relationships with industry procedures that preclude retrieval of industry-retained unpublished data on the subset of patients with preserved left ventricular function.
RESULTS
Evidence from 8 studies, including a total of 679 patients meeting the prespecified criteria for inclusion, was identified. Results were compared for BiVP versus RVP, HisBP versus RVP, and BiVP+HisBP versus RVP. Among patients who received physiologic pacing with either BiVP or HisBP, the LV end-diastolic and end-systolic volumes were significantly lower (mean duration of follow-up: 1.64 years; -2.77 mL [95% CI -4.37 to -1.1 mL]; p=0.001; and -7.09 mL [95% CI -11.27 to -2.91; p=0.0009) and LVEF remained preserved or increased (mean duration of follow-up: 1.57 years; 5.328% [95% CI: 2.86%-7.8%; p<0.0001). Data on clinical impact such as functional status and quality of life were not definitive. Data on hospitalizations were unavailable. There was no effect on mortality. Several studies stratified results by LVEF and found that patients with LVEF >35% but ≤52% were more likely to receive benefit from physiologic pacing. Patients with chronic atrial fibrillation who underwent atrioventricular node ablation and pacemaker implant demonstrated clear improvement in LVEF with BiVP or HisBP versus RVP.
CONCLUSION
Among patients with LVEF >35%, the LVEF remained preserved or increased with either BiVP or HisBP compared with RVP. However, patient-centered clinical outcome improvement appears to be limited primarily to patients who have chronic atrial fibrillation with rapid ventricular response rates and have undergone atrioventricular node ablation.
Topics: Cardiac Pacing, Artificial; Heart Block; Humans; Stroke Volume; Ventricular Remodeling
PubMed: 30412708
DOI: 10.1016/j.jacc.2018.10.045 -
JACC. Clinical Electrophysiology Jul 2020
Meta-Analysis
Topics: Arrhythmias, Cardiac; Catheter Ablation; Humans; Tachycardia, Ventricular
PubMed: 32703573
DOI: 10.1016/j.jacep.2020.04.007