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Europace : European Pacing,... Nov 2023Pulmonary vein isolation (PVI) plays a central role in the interventional treatment of atrial fibrillation (AF). Uncertainties remain about the durability of ablation... (Meta-Analysis)
Meta-Analysis
AIMS
Pulmonary vein isolation (PVI) plays a central role in the interventional treatment of atrial fibrillation (AF). Uncertainties remain about the durability of ablation lesions from different energy sources. We aimed to systematically review the durability of ablation lesions associated with various PVI-techniques using different energy sources for the treatment of AF.
METHODS AND RESULTS
Structured systematic database search for articles published between January 2010 and January 2023 reporting PVI-lesion durability as evaluated in the overall cohort through repeat invasive remapping during follow-up. Studies evaluating only a proportion of the initial cohort in redo procedures were excluded. A total of 19 studies investigating 1050 patients (mean age 60 years, 31% women, time to remap 2-7 months) were included. In a pooled analysis, 99.7% of the PVs and 99.4% of patients were successfully ablated at baseline and 75.5% of the PVs remained isolated and 51% of the patients had all PVs persistently isolated at follow-up across all energy sources. In a pooled analysis of the percentages of PVs durably isolated during follow-up, the estimates of RFA were the lowest of all energy sources at 71% (95% CI 69-73, 11 studies), but comparable with cryoballoon (79%, 95%CI 74-83, 3 studies). Higher durability percentages were reported in PVs ablated with laser-balloon (84%, 95%CI 78-89, one study) and PFA (87%, 95%CI 84-90, 2 studies).
CONCLUSION
We observed no significant difference in the durability of the ablation lesions of the four evaluated energies after adjusting for procedural and baseline populational characteristics.
Topics: Humans; Female; Middle Aged; Male; Atrial Fibrillation; Pulmonary Veins; Cryosurgery; Catheter Ablation; Time Factors; Treatment Outcome; Recurrence
PubMed: 37944133
DOI: 10.1093/europace/euad335 -
Journal of Clinical Medicine Oct 2023(1)Introduction: Catheter ablation has become a cornerstone for the management of patients with atrial fibrillation (AF). Nevertheless, recurrence rates remain high.... (Review)
Review
(1)Introduction: Catheter ablation has become a cornerstone for the management of patients with atrial fibrillation (AF). Nevertheless, recurrence rates remain high. Epicardial adipose tissue (EAT) has been associated with AF pathogenesis and maintenance. However, the literature has provided equivocal results regarding the relationship between EAT and post-ablation recurrence.(2) Purpose: to investigate the relationship between total and peri-left atrium (peri-LA) EAT with post-ablation AF recurrence. (3) Methods: major electronic databases were searched for articles assessing the relationship between EAT, quantified using computed tomography, and the recurrence of AF following catheter ablation procedures. (4) Results: Twelve studies (2179 patients) assessed total EAT and another twelve (2879 patients) peri-LA EAT. Almost 60% of the included patients had paroxysmal AF and recurrence was documented in 34%. Those who maintained sinus rhythm had a significantly lower volume of peri-LA EAT (SMD: -0.37, 95%; CI: -0.58-0.16, I2: 68%). On the contrary, no significant difference was documented for total EAT (SMD: -0.32, 95%; CI: -0.65-0.01; I2: 92%). No differences were revealed between radiofrequency and cryoenergy pulmonary venous isolation. No publication bias was identified. (5) Conclusions: Only peri-LA EAT seems to be predictive of post-ablation AF recurrence. These findings may reflect different pathophysiological roles of EAT depending on its location. Whether peri-LA EAT can be used as a predictor and target to prevent recurrence is a matter of further research.
PubMed: 37835012
DOI: 10.3390/jcm12196369 -
Cureus Aug 2023It is expected that the prevalence of atrial fibrillation (AF), the most prevalent cardiac arrhythmia among people aged 65 to 85, would be mostly classified using the... (Review)
Review
It is expected that the prevalence of atrial fibrillation (AF), the most prevalent cardiac arrhythmia among people aged 65 to 85, would be mostly classified using the CHAS2DS2-VASc approach for anticoagulation therapy. A high number of people in the entire world will be living with AF by 2030. Long-term follow-up data are sparse, although radiofrequency catheter ablation (CA) for symptomatic AF patients has the potential to be a curative therapy. Although women are referred later and less often than men, the outcomes following ablation are comparable across both genders. Health-related quality of life suffers from AF, and patients often find themselves less active as a result of their condition. AF may have a wide variety of symptoms and signs from the clinic's point of view. Women are more likely to exhibit symptoms than men; one reason for this is that women have an average QT interval that is 10-20 milliseconds longer than men, which is more likely to exacerbate tachycardia symptoms. In search of medical databases for relevant medical literature, we looked at PubMed/Medline, the Cochrane Library, and Google Scholar. Ten publications were gathered after the papers were located, assessed, and qualifying criteria applied were used to select them. The finished articles were done to give an overview of the effectiveness of ablation therapy for AF. Some studies showed that there was no statistical significance between invasive and pharmacological treatments. Other research found no difference in the recurrence of atrial arrhythmia between pulmonary vein isolation (PVI) CA alone and PVI + enhancement magnetic resonance imaging (MRI)-guided fibrosis ablation in individuals with persistent AF. The oldest individuals in studies comparing CA to medical treatment for AF demonstrated no improvement in prognosis after CA. Also, complications from therapy and CA's efficacy in preventing future atrial arrhythmias were similarly low across all age groups. Based on the above, we concluded that more studies are required to establish the most effective approach to treating AF to apply it in daily practice and gain more knowledge about it.
PubMed: 37641724
DOI: 10.7759/cureus.43992 -
Europace : European Pacing,... Aug 2023Atrial fibrillation (AF) is common in hypertrophic cardiomyopathy (HCM). There is limited data regarding the outcomes of AF catheter ablation in HCM patients. In this... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Atrial fibrillation (AF) is common in hypertrophic cardiomyopathy (HCM). There is limited data regarding the outcomes of AF catheter ablation in HCM patients. In this study, we aimed to synthesize all available evidence on the effectiveness of ablation of AF in patients with HCM compared to those without HCM.
METHODS AND RESULTS
We systematically reviewed bibliographic databases to identify studies published through February 2023. We included cohort studies with available quantitative information on rates of recurrent atrial arrhythmias, anti-arrhythmic drug (AAD) therapy, and repeat ablation procedures after initial AF ablation in patients with vs without HCM. Estimates were combined using random-effects meta-analysis models and reported as risk ratios (RR) and 95% confidence intervals (CI). Eight studies were included in quantitative synthesis (262 HCM and 642 non-HCM patients). During median follow-up 13-54 months across studies, AF recurrence rates ranged from 13.3% to 92.9% in HCM and 7.6% to 58.8% in non-HCM patients. The pooled RR for recurrent atrial arrhythmia after the first AF ablation in HCM patients compared to non-HCM controls was 1.498 (95% CI = 1.305-1.720; P < 0.001). During follow-up, HCM patients more often required AAD therapy (RR = 2.844; 95% CI = 1.713-4.856; P < 0.001) and repeat AF ablation (RR = 1.544; 95% CI = 1.070-2.228; P = 0.02). The pooled RR for recurrent atrial arrhythmias after the last AF ablation was higher in patients with HCM than those without HCM (RR = 1.607; 95% CI = 1.235-2.090; P < 0.001).
CONCLUSIONS
Compared to non-HCM patients, those with HCM had higher rates of recurrent atrial arrhythmias, AAD use, and need for repeat AF ablation after initial ablation of AF.
Topics: Humans; Atrial Fibrillation; Cardiomyopathy, Hypertrophic; Ablation Techniques; Cardiovascular Agents; Catheter Ablation
PubMed: 37595138
DOI: 10.1093/europace/euad256 -
Journal of Clinical Medicine Sep 2023Atrial fibrillation (AF) ablation is a frequent procedure used in concomitant cardiac surgery. However, uncertainty still exists concerning the optimal extent of lesion... (Review)
Review
Atrial fibrillation (AF) ablation is a frequent procedure used in concomitant cardiac surgery. However, uncertainty still exists concerning the optimal extent of lesion sets. Hence, the objective of this study was to assess the results of various ablation techniques, aiming to offer a reference for clinical decision making. This review is listed in the prospective register of systematic reviews (PROSPERO) under ID CRD42023412785. A comprehensive search was conducted across eight databases (Scopus, Google Scholar, EBSCOHost, PubMed, Medline, Wiley, ProQuest, and Embase) up to 18 April 2023. Studies were critically appraised using the Cochrane Risk of Bias 2.0 for randomized control trials (RCTs) and the Newcastle Ottawa Scale adapted by the Agency for Healthcare Research and Quality (AHRQ) for cohort studies. Forest plots of pooled effect estimates and surface under the cumulative ranking (SUCRA) were used for the analysis. Our analysis included 39 studies and a total of 7207 patients. Both bi-atrial ablation (BAA) and left atrial ablation (LAA) showed similar efficacy in restoring sinus rhythm (SR; BAA (77.9%) > LAA (76.2%) > pulmonary vein isolation (PVI; 66.5%); LAA: OR = 1.08 (CI 0.94-1.23); PVI: OR = 1.36 (CI 1.08-1.70)). However, BAA had higher pacemaker implantation (LAA: OR = 0.51 (CI 0.37-0.71); PVI: OR = 0.52 (CI 0.31-0.86)) and reoperation rates (LAA: OR = 0.71 (CI 0.28-1.45); PVI: OR = 0.31 (CI 0.1-0.64)). PVI had the lowest efficacy in restoring SR and a similar complication rate to LAA, but had the shortest procedure time (Cross-clamp (Xc): PVI (93.38) > LAA (37.36) > BAA (13.89)); Cardiopulmonary bypass (CPB): PVI (93.93) > LAA (56.04) > BAA (0.03)). We suggest that LAA is the best surgical technique for AF ablation due to its comparable effectiveness in restoring SR, its lower rate of pacemaker requirement, and its lower reoperation rate compared to BAA. Furthermore, LAA ranks as the second-fastest procedure after PVI, with a similar CPB time.
PubMed: 37685784
DOI: 10.3390/jcm12175716 -
European Journal of Medical Research Feb 2024An essential relationship between insulin resistance (IR) and atrial fibrillation (AF) has been demonstrated. Among the methods used to assess IR, the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
An essential relationship between insulin resistance (IR) and atrial fibrillation (AF) has been demonstrated. Among the methods used to assess IR, the triglyceride-glucose (TyG) index is the more straightforward, dimensionless, and low-cost tool. However, the possible usage of this index in clinical practice to predict and diagnose AF has yet to be determined and consolidated.
OBJECTIVE AND RATIONALE
Herein, we performed a systematic review and meta-analysis to assess the association between the TyG index and AF.
METHODS
Databases (PubMed, Embase, Scopus, and Web of Science) were systematically searched for studies evaluating the TyG index in AF. The inclusion criteria were observational studies investigating AF and TyG index correlation in individuals older than 18 years, while preclinical studies and those without the relevant data were excluded. Random effect meta-analyses comparing TyG levels between AF and non-AF cases, AF recurrence after radiofrequency ablation, and post-procedural AF were performed using standardized mean differences (SMD) with their matching 95% confidence intervals (CIs).
RESULTS
Our screening identified nine studies to be analyzed, including 6,171 participants including 886 with AF. The meta-analysis demonstrated that the TyG index resulted higher in patients with AF than non-AF counterparts (SMD 1.23, 95% CI 0.71 to 1.75, I 98%, P < 0.001). Subgroup analysis showed the same results for post-procedure AF (SMD 0.99, 95% CI 0.78 to 1.20, I 10%, P < 0.001) and post-ablation AF (SMD 1.25, 95% CI 1.07 to 1.43, I 46%, P < 0.001), while no difference was found in population-based cohorts (SMD 1.45, 95% CI - 0.41 to 3.31, I 100%, P = 0.13). Publication year (P = 0.036) and sample size (P = 0.003) showed significant associations with the effect size, using multivariable meta-regression.
CONCLUSION
The TyG index is an easy-to-measure surrogate marker of IR in patients with AF. Further clinical studies are warranted to demonstrate its ability for routine clinical use and as a screening tool.
Topics: Humans; Atrial Fibrillation; Glucose; Triglycerides; Biomarkers; Catheter Ablation; Insulin Resistance
PubMed: 38347644
DOI: 10.1186/s40001-024-01716-8 -
PharmacoEconomics Aug 2023Atrial fibrillation (AF) remains the most common form of cardiac arrhythmia. Management of AF aims to reduce the risk of stroke, heart failure and premature mortality...
BACKGROUND
Atrial fibrillation (AF) remains the most common form of cardiac arrhythmia. Management of AF aims to reduce the risk of stroke, heart failure and premature mortality via rate or rhythm control. This study aimed to review the literature on the cost effectiveness of treatment strategies to manage AF among adults living in low-, middle- and high-income countries.
METHODS
We searched MEDLINE (OvidSp), Embase, Web of Science, Cochrane Library, EconLit and Google Scholar for relevant studies between September 2022 and November 2022. The search strategy involved medical subject headings or related text words. Data management and selection was performed using EndNote library. The titles and abstracts were screened followed by eligibility assessment of full texts. Selection, assessment of the risk of bias within the studies, and data extraction were conducted by two independent reviewers. The cost-effectiveness results were synthesised narratively. The analysis was performed using Microsoft Excel 365. The incremental cost effectiveness ratio for each study was adjusted to 2021 USD values.
RESULTS
Fifty studies were included in the analysis after selection and risk of bias assessment. In high-income countries, apixaban was predominantly cost effective for stroke prevention in patients at low and moderate risk of stroke, while left atrial appendage closure (LAAC) was cost effective in patients at high risk of stroke. Propranolol was the cost-effective choice for rate control, while catheter ablation and the convergent procedure were cost-effective strategies in patients with paroxysmal and persistent AF, respectively. Among the anti-arrhythmic drugs, sotalol was the cost-effective strategy for rhythm control. In middle-income countries, apixaban was the cost-effective choice for stroke prevention in patients at low and moderate risk of stroke while high-dose edoxaban was cost effective in patients at high risk of stroke. Radiofrequency catheter ablation was the cost-effective option in rhythm control. No data were available for low-income countries.
CONCLUSION
This systematic review has shown that there are several cost-effective strategies to manage AF in different resource settings. However, the decision to use any strategy should be guided by objective clinical and economic evidence supported by sound clinical judgement.
REGISTRATION
CRD42022360590.
Topics: Adult; Humans; Atrial Fibrillation; Cost-Effectiveness Analysis; Developed Countries; Cost-Benefit Analysis; Stroke
PubMed: 37204698
DOI: 10.1007/s40273-023-01276-5 -
Cureus Dec 2023Despite the potential of cardiac rehabilitation (CR) to reduce atrial fibrillation (AF) recurrence after radiofrequency catheter ablation (RFCA), its prescription is not... (Review)
Review
Safety and Effectiveness of Exercise-Based Cardiac Rehabilitation for Patients With Atrial Fibrillation Following Radiofrequency Catheter Ablation Therapy: A Systematic Review and Meta-Analysis.
Despite the potential of cardiac rehabilitation (CR) to reduce atrial fibrillation (AF) recurrence after radiofrequency catheter ablation (RFCA), its prescription is not routine. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of CR in this setting. Inclusion criteria comprised randomized controlled trials (RCTs) comparing CR with usual care in patients with AF following RFCA. We performed a comprehensive search of six databases up to August 17, 2023, and conducted a thorough risk of bias assessment. We synthesized safety outcomes using AF recurrence rates to calculate relative risks (RR). Furthermore, we conducted a meta-analysis on peak oxygen uptake (VO peak) and the six-minute walk test (6MWT) to gauge efficacy, utilizing mean differences (MD) for comparison. The GRADE framework was employed to determine the certainty of evidence, with two independent reviewers completing all processes. Our analysis encompassed eight studies with 772 participants aged 55-70 years engaged in moderate-intensity CR for a median of six months. Results showed no significant difference in AF recurrence after CR (RR = 0.69 (0.41-1.14)), with low evidence certainty due to heterogeneity. Subgroup analyses suggested a poor risk reduction effect in patients with obesity and persistent AF. Significant improvements were observed in VO peak and 6MWT outcomes (VO peak; MD = 2.53 (0.78-4.28), 6MWT; MD = 38.81 (0.65-76.97)), with moderate-certainty evidence. While CR may decrease AF recurrence after RFCA, its effectiveness varies, potentially diminishing in patients with obesity or persistent AF. Moderate gains in physical performance were achieved with minimal adverse events. Further RCTs are warranted to confirm these findings.
PubMed: 38094881
DOI: 10.7759/cureus.50476 -
European Heart Journal. Quality of Care... Aug 2023Catheter ablation of atrial fibrillation (AF) is now a mainstream procedure although long-term outcomes are uncertain. We performed a systematic review and meta-analysis... (Meta-Analysis)
Meta-Analysis
AIMS
Catheter ablation of atrial fibrillation (AF) is now a mainstream procedure although long-term outcomes are uncertain. We performed a systematic review and meta-analysis of procedural outcomes at 5 years and beyond.
METHODS AND RESULTS
We searched PubMed and Embase and after the screening, identified 73 studies (67 159 patients) reporting freedom from atrial arrhythmia, all-cause death, stroke, and major bleeding at ≥5 years after AF ablation. The pooled mean age was 59.7y, 71.5% male, 62.2% paroxysmal AF, and radiofrequency was used in 78.1% of studies. Pooled incidence of freedom from atrial arrhythmia at 5 years was 50.6% (95%CI 45.5-55.7%) after a single ablation and 69.7% [95%CI (confidence interval) 63.8-75.3%) after multiple procedures. The incidence was higher among patients with paroxysmal compared with non-paroxysmal AF after single (59.7% vs. 33.3%, p = 0.002) and multiple (80.8% vs. 60.6%, p < 0.001) ablations but was comparable between radiofrequency and cryoablation. Pooled incidences of other outcomes were 6.0% (95%CI 3.2-9.7%) for death, 2.4% (95%CI 1.4-3.7%) for stroke, and 1.2% (95%CI 0.8-2.0%) for major bleeding at 5 years. Beyond 5 years, freedom from arrhythmia recurrence remained largely stable (52.3% and 64.7% after single and multiple procedures at 10 years), while the risk of stroke and bleeding increased over time.
CONCLUSION
Nearly 70% of patients having multiple ablations remained free from atrial arrhythmia at 5 years, with the incidence slightly decreasing beyond this period. Risk of death, stroke, and major bleeding at 5 years were low but increased over time, emphasizing the importance of long-term thromboembolism prevention and bleeding risk management.
Topics: Humans; Male; Middle Aged; Female; Atrial Fibrillation; Treatment Outcome; Anti-Arrhythmia Agents; Hemorrhage; Stroke; Catheter Ablation
PubMed: 37336617
DOI: 10.1093/ehjqcco/qcad037 -
Annals of Cardiothoracic Surgery Mar 2024Atrial fibrillation (AF) is the most common arrhythmia, and is also associated with mitral valve disease. Although the benefits of robotic mitral valve surgery are well...
BACKGROUND
Atrial fibrillation (AF) is the most common arrhythmia, and is also associated with mitral valve disease. Although the benefits of robotic mitral valve surgery are well documented, literature combining robotic mitral valve surgery with AF surgery remains sparse. The aim of this systematic review and meta-analysis is to evaluate the evidence assessing the efficacy and safety of AF ablation during robotic mitral valve surgery.
METHODS
Five electronic databases were searched from inception to April 2023. All studies reporting the primary outcome, freedom from AF, for patients with a history of AF undergoing robotic mitral valve surgery and AF ablation were identified. Studies which included mixed cohorts, or patients who did not undergo robotic mitral valve surgery were excluded. Relevant data were extracted and a meta-analysis of proportions was conducted using a random-effects model.
RESULTS
Five studies were included with a total of 241 patients. Cohort sizes ranged from 11 to 94 patients. The aggregate mean age was 58.5 years and patients had persistent AF (71.1%). All five studies utilised the da Vinci Surgical System, and performed variable lesion sets. The freedom from AF was 88.1% at a weighted mean follow-up of 6.9 months. There were two mortalities (0.8%), two patients required conversion to sternotomy (1.4%) and eight required a permanent pacemaker (3.7%).
CONCLUSIONS
AF ablation with robotic mitral valve surgery can be performed with adequate short-term efficacy and safety profile. Current evidence on AF ablation and robotic mitral valve surgery is limited to low-quality retrospective data with inherent selection bias. Further large-scale prospective data is required to verify these results.
PubMed: 38590987
DOI: 10.21037/acs-2023-afm-20