Special Issue "New Approaches to the Atrial Fibrillation Management"

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (31 January 2020).

Special Issue Editors

Prof. Dr. Natasja M.S. de Groot
E-Mail Website
Guest Editor
Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
Interests: mapping of atrial fibrillation in order to identify novel targets for therapy; arrhythmias in patients with congenital heart disease
Prof. Dr. Bianca Brundel
E-Mail Website
Guest Editor
Department of Physiology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, The Netherlands
Interests: role of protein homeostasis and the protein quality control system underlying atrial fibrillation; novel druggable targets for the therapy of atrial fibrillation
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Special Issue Information

Dear Colleagues,

Age-related, progressive arrhythmia atrial fibrillation (AF) is the cardiovascular epidemic of the 21th century. The increase in the number of patients with AF is associated with the ageing of populations suffering from a variety of cardiovascular diseases because of the improved clinical care. The development of AF depends on the presence of triggers, initiators, and substrates, and is treated with drugs, implantable devices (electrical stimulation/defibrillation therapy), and catheter-based ablative therapy. Unfortunately, the currently available therapies are moderately effective and can have serious side-effects. There are several explanations for therapy failure. In case of trigger-driven AF, recurrences after ablative therapy are the result of a reconduction across the ablation lesions. In substrate-mediated patients, AF is caused by “electropathology”, which is defined as abnormalities in electrical impulse formation or conduction as a result of the structural damage of cardiac tissue. The exact electrical and molecular mechanisms underlying AF are at present only partly known. The severity of electropathology determines which treatment modality is the most effective, and is therefore indispensable in guiding therapy. However, there are insufficient (pharmaco) therapeutic tools to target the underlying electropathological substrate. Hence, the development of patient-tailored diagnostic tools and innovative therapies is of paramount importance in order to improve arrhythmia-free survival. In the past decades, many novel therapies for patients with AF have been developed with a variety of targets, ranging from the prevention of thrombo-embolic complications, to complex ablation strategies. The aim of this Special Issue is to discuss the contribution of novel approaches to advances in the management of patients with AF.

Prof. Dr. Natasja M.S. de Groot
Prof. Dr. Bianca Brundel
Guest Editors

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Keywords

  • mapping-guided therapy
  • novel pharmacological therapies
  • preventive pacing
  • ablation therapy
  • left atrial appendage occluding devices
  • surgical AF therapy
  • novel anti-coagulation therapies

Published Papers (15 papers)

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Article
Long-Term Survival Following Surgical Ablation for Atrial Fibrillation Concomitant to Isolated and Combined Coronary Artery Bypass Surgery—Analysis from the Polish National Registry of Cardiac Surgery Procedures (KROK)
J. Clin. Med. 2020, 9(5), 1345; https://doi.org/10.3390/jcm9051345 - 04 May 2020
Cited by 2 | Viewed by 807
Abstract
The current investigation aimed to evaluate long-term survival in patients undergoing isolated and combined coronary artery bypass grafting (CABG) with concomitant surgical ablation for atrial fibrillation (AF). Procedural data from KROK (Polish National Registry of Cardiac Surgery Procedures) were retrospectively collected. Eleven thousand [...] Read more.
The current investigation aimed to evaluate long-term survival in patients undergoing isolated and combined coronary artery bypass grafting (CABG) with concomitant surgical ablation for atrial fibrillation (AF). Procedural data from KROK (Polish National Registry of Cardiac Surgery Procedures) were retrospectively collected. Eleven thousand three hundred sixteen patients with baseline AF (72.4% men, mean age 69.6 ± 7.9) undergoing isolated and combined CABG surgery between 2006–2019 in 37 reference centers across Poland and included in the registry were analyzed. The median follow-up was four years (3.7 IQR 1.3–6.8). Over a 12-year study period, there was a significant survival benefit (Hazard Ratio (HR) 0.83; (95% Confidence Interval (CI): 0.73–0.95); p = 0.005) with concomitant ablation as compared to no concomitant ablation. After rigorous propensity matching (LOGIT model, 432 pairs), concomitant surgical ablation was associated with over 25% improved survival in the overall analysis: HR 0.74; (95% CIs: 0.56–0.98); p = 0.036. The benefit of concomitant ablation was maintained in the subgroups, yet the most benefit was appraised in low-risk patients (EuroSCORE < 2, p = 0.003) with the three-vessel disease (p < 0.001) and without other comorbidities. Ablation was further associated with significantly improved survival in patients undergoing CABG with mitral valve surgery (HR 0.62; (95% CIs: 0.52–0.74); p < 0.001) and in patients in whom complete revascularization was not achieved: HR 0.43; (95% CIs: 0.24–0.79); p = 0.006. Full article
(This article belongs to the Special Issue New Approaches to the Atrial Fibrillation Management)
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Article
Compliance of Atrial Fibrillation Treatment with the Atrial Fibrillation Better Care (ABC) Pathway Improves the Clinical Outcomes in the Middle East Population: A Report from the Gulf Survey of Atrial Fibrillation Events (SAFE) Registry
J. Clin. Med. 2020, 9(5), 1286; https://doi.org/10.3390/jcm9051286 - 29 Apr 2020
Cited by 4 | Viewed by 800
Abstract
Atrial fibrillation (AF) is associated with substantially increased risk of cardiovascular events and overall mortality. The Atrial fibrillation Better Care (A—Avoid stroke, B—Better symptom management, C—Cardiovascular and comorbidity risk management) pathway provides a simple and comprehensive approach for integrated [...] Read more.
Atrial fibrillation (AF) is associated with substantially increased risk of cardiovascular events and overall mortality. The Atrial fibrillation Better Care (A—Avoid stroke, B—Better symptom management, C—Cardiovascular and comorbidity risk management) pathway provides a simple and comprehensive approach for integrated AF therapy. This study’s goals were to evaluate the ABC pathway compliance and determine the main gaps in AF management in the Middle East population, and to assess the impact of ABC pathway adherence on the all-cause mortality and composite outcome in AF patients. 2021 patients (mean age 57; 52% male) from the Gulf SAFE registry were studied. We evaluated: A—appropriate implementation of OACs according to CHA2DS2-VASc score; B—symptom control according to European Heart Rhythm Association (EHRA) symptom scale; C—proper cardiovascular comorbidities management. The primary endpoints were the composite cardiovascular outcome (ischemic stroke or systemic embolism, all-cause death and cardiovascular hospitalization) and all-cause mortality. One-hundred and sixty-eight (8.3%) patients were optimally managed according to adherence with the ABC pathway. Over the one-year follow up (FU), there were 578 composite outcome events and 224 deaths. Patients managed with integrated care had significantly lower rates for the composite outcome and mortality comparing to non-ABC group (20.8% vs. 29.3%, p = 0.02 and 7.3% vs. 13.1%, p = 0.033, respectively). On multivariable analysis, ABC compliance was independently associated with reduced risk of composite outcome (HR 0.53; 95% CI 0.36–0.8, p = 0.002) and death (HR 0.46; 95% CI 0.25–0.86, p = 0.015). Integrated ABC pathway adherent care resulted in the reduced composite outcome and all-cause mortality in AF patients from Middle East, highlighting the necessity of promoting comprehensive holistic and integrated care management of AF. Full article
(This article belongs to the Special Issue New Approaches to the Atrial Fibrillation Management)
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Article
The Wearable Cardioverter-Defibrillator: Experience in 153 Patients and a Long-Term Follow-Up
J. Clin. Med. 2020, 9(3), 893; https://doi.org/10.3390/jcm9030893 - 24 Mar 2020
Cited by 2 | Viewed by 1194
Abstract
Background: The wearable cardioverter-defibrillator (WCD) is available for patients at high risk for sudden cardiac death (SCD) when immediate implantable cardioverter-defibrillator (ICD) implantation is not possible or indicated. Patient selection remains challenging especially in primary prevention. Long-term data on these patients is still [...] Read more.
Background: The wearable cardioverter-defibrillator (WCD) is available for patients at high risk for sudden cardiac death (SCD) when immediate implantable cardioverter-defibrillator (ICD) implantation is not possible or indicated. Patient selection remains challenging especially in primary prevention. Long-term data on these patients is still lacking. Methods: 153 patients were included in this study. They were prescribed the WCD between April 2012 and March 2019 at the University Medical Center, Mannheim, Germany. The mean follow-up period was 36.2 ± 15.6 months. Outcome data, including all-cause mortality, were analyzed by disease etiology and ICD implantation following WCD use. Results: We analyzed 56 patients with ischemic cardiomyopathy, 70 patients with non-ischemic cardiomyopathy, 16 patients with prior need for ICD/CRT-D (device for cardiac resynchronization therapy with defibrillator) explanation, 8 patients with acute myocarditis and 3 patients with congenital diseases. 58% of the patients did not need ICD/CRT-D implantation after WCD use. 4% of all patients suffered from appropriate WCD shocks. 2 of these patients (33%) experienced appropriate ICD shocks after implantation due to ventricular tachyarrhythmias. Long-term follow-up shows a good overall survival. All-cause mortality was 10%. There was no significant difference between patients with or without subsequent ICD implantation (p = 0.48). Patients with ischemic cardiomyopathy numerically showed a higher long-term mortality than patients with non-ischemic cardiomyopathy (14% vs. 6%, p = 0.13) and received significantly more ICD shocks after implantation (10% of ischemic cardiomyopathy (ICM) patients versus 3% of non-ischemic cardiomyopathy (NICM) patients, p = 0.04). All patients with ventricular tachyarrhythmias during WCD use or after ICD implantation survived the follow-up period. Conclusion: Following WCD use, ICD implantation could be avoided in 58% of patients. Long-term follow-up shows good overall survival. The majority of all patients did not suffer from WCD shocks nor did receive ICD shocks after subsequent implantation. Patient selection regarding predictive conditions on long-term risk of ventricular tachyarrhythmias needs further risk stratification. Full article
(This article belongs to the Special Issue New Approaches to the Atrial Fibrillation Management)
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Article
Impact of the Fibrosis-4 Index on Risk Stratification of Cardiovascular Events and Mortality in Patients with Atrial Fibrillation: Findings from a Japanese Multicenter Registry
J. Clin. Med. 2020, 9(2), 584; https://doi.org/10.3390/jcm9020584 - 21 Feb 2020
Cited by 6 | Viewed by 908
Abstract
Background: Liver diseases drive the development and progression of atrial fibrillation (AF). The Fibrosis-4 (FIB4) index is a non-invasive scoring method for detecting liver fibrosis, but the prognostic impact of using it for AF patients is still unknown. Herein, we evaluated using the [...] Read more.
Background: Liver diseases drive the development and progression of atrial fibrillation (AF). The Fibrosis-4 (FIB4) index is a non-invasive scoring method for detecting liver fibrosis, but the prognostic impact of using it for AF patients is still unknown. Herein, we evaluated using the FIB4 index as a risk assessment tool for cardiovascular events and mortality in patients with AF. Methods: We performed a post-hoc analysis of a prospective, observational multicenter study. A total of 3067 patients enrolled in a multicenter Japanese registry were grouped as first tertile (FIB4 index < 1.75, n = 1022), second tertile (1.75 ≤ FIB4 index < 2.51, n = 1022), and third tertile (FIB4 index ≥ 2.51, n = 1023). Results: The third tertile had statistically significant results: older age, lower body mass index, increased heart failure prevalence, and lower clearances of hemoglobin and creatinine (all p < 0.05). During the follow-up period, incidences of major bleeding, cardiovascular events, and all-cause mortality were significantly higher for the third tertile (all p < 0.05). After multivariate adjustment, the third tertile associated independently with cardiovascular events (HR 1.72; 95% CI 1.31–2.25) and all-cause mortality (HR 1.43; 95% CI 1.06–1.95). Adding the FIB4 index to a baseline model with CHA2DS2-VASc score improved the prediction of cardiovascular events and all-cause mortality, as shown by the significant increase in the C-statistic (all p < 0.05), net reclassification improvement (all p < 0.001), and integrated discrimination improvement (all p < 0.001). A FIB4 index ≥ 2.51 most strongly associated with cardiovascular events and all-cause mortality in AF patients with high CHADS2 scores (all p < 0.001). Conclusions: The FIB4 index is independently associated with risks of cardiovascular events and all-cause mortality in AF patients. Full article
(This article belongs to the Special Issue New Approaches to the Atrial Fibrillation Management)
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Article
Atrial Ectopy Increases Asynchronous Activation of the Endo- and Epicardium at the Right Atrium
J. Clin. Med. 2020, 9(2), 558; https://doi.org/10.3390/jcm9020558 - 18 Feb 2020
Cited by 2 | Viewed by 525
Abstract
The predisposition of atrial extrasystoles (AES) to trigger cardiac tachyarrhythmia may arise from intramural conduction disorders causing endo-epicardial asynchrony (EEA). This study aimed to determine whether spontaneous AES disturb endo-epicardial conduction. Simultaneous endo-epicardial mapping of the right atrium was performed in patients during [...] Read more.
The predisposition of atrial extrasystoles (AES) to trigger cardiac tachyarrhythmia may arise from intramural conduction disorders causing endo-epicardial asynchrony (EEA). This study aimed to determine whether spontaneous AES disturb endo-epicardial conduction. Simultaneous endo-epicardial mapping of the right atrium was performed in patients during cardiac surgery with two 128-electrode arrays. Sixty spontaneous AES were observed in 23 patients and were analyzed for incidence of conduction delay, conduction block and amount of EEA compared to the previous sinus rhythm beat. Both conduction delay and block occurred more often in AES compared to sinus rhythm. The difference in lines of conduction block between the epicardium and endocardium increased in AES causing a greater imbalance of conduction disorders between the layers. The incidence of EEA with differences ≥10 ms increased significantly in AES. AES caused delays between the epicardium and endocardium up to 130 ms and EEA to increase for up to half (47%) of the mapping area. Conduction disturbances between the epicardial and endocardial layer giving rise to EEA increase during AES. Asynchronous activation of the atrial layers increases during AES which may be a mechanism for triggering cardiac tachyarrhythmia under the right conditions but EEA cannot be recognized by current mapping tools. Full article
(This article belongs to the Special Issue New Approaches to the Atrial Fibrillation Management)
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Article
Pulmonary Vein Enlargement as an Independent Predictor for New-Onset Atrial Fibrillation
J. Clin. Med. 2020, 9(2), 401; https://doi.org/10.3390/jcm9020401 - 02 Feb 2020
Cited by 1 | Viewed by 592
Abstract
Pulmonary vein (PV) enlargement is associated with atrial fibrillation (AF). However, the predictive value of PV volume for new-onset AF has not been determined. We retrospectively assessed and enrolled non-AF subjects who underwent echocardiography and cardiac CT angiography (CCTA) around the same time [...] Read more.
Pulmonary vein (PV) enlargement is associated with atrial fibrillation (AF). However, the predictive value of PV volume for new-onset AF has not been determined. We retrospectively assessed and enrolled non-AF subjects who underwent echocardiography and cardiac CT angiography (CCTA) around the same time and evaluated the development of AF longitudinally. PV volume was assessed by estimating the three-dimensional CCTA-derived mid-diastolic PV volume from the ostium to tertiary branches. Overall, 1105 subjects were enrolled. Among them, 29 developed AF during a mean follow-up of 4.28 ± 3.08 years after baseline CCTA and echocardiography. The AF group had a higher proportion of older aged subjects, a higher ratio of early mitral flow velocity (E) to early mitral annular tissue velocity (Em), higher Em, and larger left atrial (LAVI) and PV (PVVI) volume indices. PVVI was independently associated with male sex, left ventricular dimension, E/Em and LAVI. AF incidence increased markedly across each baseline PVVI tertile (2.2%, 5.1%, and 10.8%). In the multivariate Cox model, increased PVVI was independently associated with new-onset AF (hazard ratio (HR) = 5.401, 4.931–6.193, p = 0.007). Based on the analysis of multimodal cardiac imaging, our results provide mechanistic insights into PV remodeling and its potential role as a link between diastolic dysfunction and developing AF. Full article
(This article belongs to the Special Issue New Approaches to the Atrial Fibrillation Management)
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Article
Relationship between Atrial Tachyarrhythmias and Intrathoracic Impedance in Patients with a Pacemaker and Preserved Ejection Fraction
J. Clin. Med. 2020, 9(1), 105; https://doi.org/10.3390/jcm9010105 - 31 Dec 2019
Cited by 1 | Viewed by 704
Abstract
Atrial fibrillation (AF) is responsible for significant morbidity and mortality in patients with heart failure (HF). Modern pacemakers provide an index of intrathoracic fluid status (OptiVol fluid index—OVFI) by measuring daily intrathoracic impedance. This study aimed to determine whether OVFI is associated with [...] Read more.
Atrial fibrillation (AF) is responsible for significant morbidity and mortality in patients with heart failure (HF). Modern pacemakers provide an index of intrathoracic fluid status (OptiVol fluid index—OVFI) by measuring daily intrathoracic impedance. This study aimed to determine whether OVFI is associated with increased atrial tachycardia/fibrillation (AT/AF) events in patients with a preserved ejection fraction (EF). We retrospectively reviewed data from patients with Medtronic Advisa pacemakers between 2012 and 2014 in our hospital. The association and temporal relationship between OVFI and AT/AF events were determined. A total of 150 patients with 211 follow-up visits (mean 1.4 visits per patient) were evaluated. The device-detected AT/AF prevalence was 47%. Device-measured OVFI ≥ 20 Ω-days was significantly associated with the onset of AT/AF ≥ 4 h. OVFI threshold crossing preceded AT/AF events in 55.1% of cases, followed by AT/AF events in only 18.7%. Fluid overload represented by OVFI may trigger AT/AF episodes in patients with a preserved EF more often than that previously reported in patients with a reduced EF. Our findings support the view that worsening pulmonary congestion is associated with increased AT/AF frequency and suggests that fluid overload could trigger and perpetuate AT/AF events in patients with a preserved EF. Full article
(This article belongs to the Special Issue New Approaches to the Atrial Fibrillation Management)
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Article
Atrial Fibrillation Progression Is Associated with Cell Senescence Burden as Determined by p53 and p16 Expression
J. Clin. Med. 2020, 9(1), 36; https://doi.org/10.3390/jcm9010036 - 23 Dec 2019
Cited by 3 | Viewed by 1082
Abstract
Background: Whilst the link between aging and thrombogenicity in atrial fibrillation (AF) is well established, the cellular underlying mechanisms are unknown. In AF, the role of senescence in tissue remodeling and prothrombotic state remains unclear. Aims: We investigated the link between AF and [...] Read more.
Background: Whilst the link between aging and thrombogenicity in atrial fibrillation (AF) is well established, the cellular underlying mechanisms are unknown. In AF, the role of senescence in tissue remodeling and prothrombotic state remains unclear. Aims: We investigated the link between AF and senescence by comparing the expression of senescence markers (p53 and p16), with prothrombotic and inflammatory proteins in right atrial appendages from patients in AF and sinus rhythm (SR). Methods: The right atrial appendages of 147 patients undergoing open-heart surgery were harvested. Twenty-one non-valvular AF patients, including paroxysmal (PAF) or permanent AF (PmAF), were matched with 21 SR patients according to CHA2DS2-VASc score and treatment. Protein expression was assessed by tissue lysates Western blot analysis. Results: The expression of p53, p16, and tissue factor (TF) was significantly increased in AF compared to SR (0.91 ± 0.31 vs. 0.58 ± 0.31, p = 0.001; 0.76 ± 0.32 vs. 0.35 ± 0.18, p = 0.0001; 0.88 ± 0.32 vs. 0.68 ± 0.29, p = 0.045, respectively). Expression of endothelial NO synthase (eNOS) was lower in AF (0.25 ± 0.15 vs. 0.35 ± 0.12, p = 0.023). There was a stepwise increase of p53, p16, TF, matrix metalloproteinase-9, and an eNOS progressive decrease between SR, PAF, and PmAF. AF was the only predictive factor of p53 and p16 elevation in multivariate analysis. Conclusions: The study brought new evidence indicating that AF progression is strongly related to human atrial senescence burden and points at a link between senescence, thrombogenicity, endothelial dysfunction and atrial remodeling. Full article
(This article belongs to the Special Issue New Approaches to the Atrial Fibrillation Management)
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Article
Comparison of Renal Function Estimation Formulae for Dosing Direct Oral Anticoagulants in Patients with Atrial Fibrillation
J. Clin. Med. 2019, 8(12), 2034; https://doi.org/10.3390/jcm8122034 - 21 Nov 2019
Cited by 6 | Viewed by 893
Abstract
The Cockcroft-Gault (CG) formula is recommended to guide clinicians in the choice of the appropriate dosage for direct oral anticoagulants (DOACs). However, the performance of the CG formula varies depending on the patient’s age, weight, and degree of renal function. We aimed to [...] Read more.
The Cockcroft-Gault (CG) formula is recommended to guide clinicians in the choice of the appropriate dosage for direct oral anticoagulants (DOACs). However, the performance of the CG formula varies depending on the patient’s age, weight, and degree of renal function. We aimed to compare the validity of the CG formula with that of Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Modification of Diet in Renal Disease (MDRD) formulae for dosing DOACs. A total of 6268 consecutive patients on anticoagulants for atrial fibrillation (AF) were retrospectively investigated. Among underweight and elderly patients, the CG formula underestimated renal function compared with the non-CG formulae. However, the concordant rate of drug indications between the CG and the non-CG formulae was approximately 94%. On-label uses under the three formulae were associated with a lower risk of major bleeding (but not thromboembolism) compared to warfarin. Although we found differences in estimating renal function and the proportions of drug indications between the CG and non-CG formulae, the risks of thromboembolism and major bleeding were similar to those with warfarin regardless of which formula was used. Full article
(This article belongs to the Special Issue New Approaches to the Atrial Fibrillation Management)
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Article
Symbolic Recurrence Analysis of RR Interval to Detect Atrial Fibrillation
J. Clin. Med. 2019, 8(11), 1840; https://doi.org/10.3390/jcm8111840 - 02 Nov 2019
Cited by 3 | Viewed by 1154
Abstract
Atrial fibrillation (AF) is a sustained cardiac arrhythmia associated with stroke, heart failure, and related health conditions. Though easily diagnosed upon presentation in a clinical setting, the transient and/or intermittent emergence of AF episodes present diagnostic and clinical monitoring challenges that would ideally [...] Read more.
Atrial fibrillation (AF) is a sustained cardiac arrhythmia associated with stroke, heart failure, and related health conditions. Though easily diagnosed upon presentation in a clinical setting, the transient and/or intermittent emergence of AF episodes present diagnostic and clinical monitoring challenges that would ideally be met with automated ambulatory monitoring and detection. Current approaches to address these needs, commonly available both in smartphone applications and dedicated technologies, combine electrocardiogram (ECG) sensors with predictive algorithms to detect AF. These methods typically require extensive preprocessing, preliminary signal analysis, and the integration of a wide and complex array of features for the detection of AF events, and are consequently vulnerable to over-fitting. In this paper, we introduce the application of symbolic recurrence quantification analysis (SRQA) for the study of ECG signals and detection of AF events, which requires minimal pre-processing and allows the construction of highly accurate predictive algorithms from relatively few features. In addition, this approach is robust against commonly-encountered signal processing challenges that are expected in ambulatory monitoring contexts, including noisy and non-stationary data. We demonstrate the application of this method to yield a highly accurate predictive algorithm, which at optimal threshold values is 97.9% sensitive, 97.6% specific, and 97.7% accurate in classifying AF signals. To confirm the robust generalizability of this approach, we further evaluated its performance in the implementation of a 10-fold cross-validation paradigm, yielding 97.4% accuracy. In sum, these findings emphasize the robust utility of SRQA for the analysis of ECG signals and detection of AF. To the best of our knowledge, the proposed model is the first to incorporate symbolic analysis for AF beat detection. Full article
(This article belongs to the Special Issue New Approaches to the Atrial Fibrillation Management)
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Article
Atrial Fibrillation Ablation with Multipolar Phased-Radiofrequency Catheter: The Learning Curve Effect for Procedural Parameters, but not for the Long-Term Outcome
J. Clin. Med. 2019, 8(10), 1589; https://doi.org/10.3390/jcm8101589 - 02 Oct 2019
Cited by 2 | Viewed by 844
Abstract
Background: Pulmonary vein isolation (PVI) is a routine treatment in atrial fibrillation (AF). Single-shot techniques were introduced to simplify the procedure. We analyzed time-dependent changes in procedural parameters, acute success, complication rates, and long-term outcomes during our initial experience with multipolar phased-radiofrequency (RF) [...] Read more.
Background: Pulmonary vein isolation (PVI) is a routine treatment in atrial fibrillation (AF). Single-shot techniques were introduced to simplify the procedure. We analyzed time-dependent changes in procedural parameters, acute success, complication rates, and long-term outcomes during our initial experience with multipolar phased-radiofrequency (RF) ablation. Methods and Results: The first 126 consecutive patients (98 male; age: 58.8 ± 8.7 years) who underwent PVI with phased-RF ablation at our center were included in the study. Procedural parameters, complication rate, acute success and 12-month efficacy were compared in the first, second and third group of 42 consecutive patients. In all patients, 516/526 PVs were effectively isolated (98.1%), with no differences between the tierces (p = 0.67). Procedure (169.8 vs. 132.9 vs. 105.8 min, p < 0.0001), fluoroscopy (32.9 vs. 24.3 vs. 14.1 min, p < 0.0001) and left atrial dwell (83.0 vs. 61.9 vs. 51.4 min, p < 0.0001) times were significantly reduced with experience in tierces 1–3, respectively. In the 12-month follow-up, 60.3% of patients were arrhythmia-free with no differences between the tierces (p = 0.88). In multivariate analysis, the relapse in the blanking period (p < 0.0001), time from AF diagnosis (p = 0.004) and left atrial diameter (p = 0.012) were the only independent predictors of AF recurrence. Conclusions: The learning curve effect was demonstrated in procedural parameters, but not in the complication rate nor the long-term success of PVI with phased-RF technique. The relapse in the blanking period was the strongest predictor of treatment failure in long-time observation. Full article
(This article belongs to the Special Issue New Approaches to the Atrial Fibrillation Management)
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Article
Effects of Prevalent and Incident Atrial Fibrillation on Renal Outcome, Cardiovascular Events, and Mortality in Patients with Chronic Kidney Disease
J. Clin. Med. 2019, 8(9), 1378; https://doi.org/10.3390/jcm8091378 - 03 Sep 2019
Cited by 4 | Viewed by 975
Abstract
Background: Little is known about how incident atrial fibrillation (AF) affects the clinical outcomes in chronic kidney disease (CKD) patients and whether there is a different influence between pre-existing and incident AF. Methods: Incident CKD patients from 2000 to 2013 were retrieved from [...] Read more.
Background: Little is known about how incident atrial fibrillation (AF) affects the clinical outcomes in chronic kidney disease (CKD) patients and whether there is a different influence between pre-existing and incident AF. Methods: Incident CKD patients from 2000 to 2013 were retrieved from the National Health Insurance Research Database (NHIRD) of Taiwan and they were classified as non-AF (n = 15,251), prevalent AF (n = 612), and incident AF (n = 588). The outcomes of interest were end-stage renal disease (ESRD) requiring dialysis, all-cause mortality, cardiovascular (CV) mortality, acute myocardial infarction (AMI), stroke or systemic thromboembolism. Results: Compared with CKD patients without AF, those with prevalent or incident AF were associated with higher adjusted rates of ESRD (hazard ratio (HR), 1.40; 95% confidence interval (CI), 1.32–1.48; HR, 2.91; 95% CI, 2.74–3.09, respectively), stroke or systemic thromboembolism (HR, 1.89; 95% CI, 1.77–2.03; HR, 1.67; 95% CI, 1.54–1.81, respectively), AMI (HR, 1.24; 95% CI, 1.09–1.41; HR, 1.99; 95% CI, 1.75–2.27, respectively), all-cause mortality (HR, 1.64; 95% CI, 1.56–1.72; HR, 2.17; 95% CI, 2.06–2.29, respectively), and CV mortality (HR, 2.95; 95% CI, 2.62–3.32; HR, 4.61; 95% CI, 4.09–5.20, respectively). Intriguingly, CKD patients with prevalent AF were associated with lower adjusted rates of ESRD, AMI, all-cause mortality, and CV mortality compared with those with incident AF. Conclusion: Both incident and prevalent AF were independently associated with greater risks of AMI, all-cause mortality, CV mortality, ESRD, and stroke or systemic thromboembolism. Our findings are novel in that, compared with prevalent AF, incident AF possessed an even higher risk of some clinical consequences, including ESRD, all-cause mortality, CV mortality, and AMI. Full article
(This article belongs to the Special Issue New Approaches to the Atrial Fibrillation Management)
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Article
Atrial Fibrillation: A New Indicator for Advanced Colorectal Neoplasia in Screening Colonoscopy
J. Clin. Med. 2019, 8(7), 1083; https://doi.org/10.3390/jcm8071083 - 23 Jul 2019
Cited by 1 | Viewed by 1329
Abstract
Background: Colorectal cancer (CRC) is a common and potentially preventable malignancy. Evidence has emerged that coronary artery disease patients are at increased risk for developing CRC by shared risk factors. Here we investigated an association between CRC and atrial fibrillation (AF), a surrogate [...] Read more.
Background: Colorectal cancer (CRC) is a common and potentially preventable malignancy. Evidence has emerged that coronary artery disease patients are at increased risk for developing CRC by shared risk factors. Here we investigated an association between CRC and atrial fibrillation (AF), a surrogate marker of cardiovascular risk, in the setting of routine screening colonoscopy. Methods: We investigated 1949 asymptomatic participants (median age 61 [54–67] years, 49% females) undergoing screening colonoscopy within the SAKKOPI registry (Salzburg Colon Cancer Prevention Initiative). Forty-six participants with AF (2.4%) were identified, and colonoscopy findings were compared to non-AF participants. Propensity Score Matching (PSM) was used to create 1:1 and 3:1 age- and gender-matched couples. Results: Abnormal findings on screening colonoscopy (any form of adenoma or carcinoma) were more common in AF participants with an odds ratios (OR) of 2.4 [1.3–4.3] in the unmatched analysis, and 2.6 [1.1–6.3] and 2.0 [1.1–4.0] in the 1:1 and 3:1 matched groups, respectively. Correspondingly, the odds of finding advanced adenomas or carcinomas was elevated about three-fold across the different matched and unmatched analyses (OR 3.3 [1.1–10.8] for 3:1 matched participants). At the same time, the prevalence and number of colonic lesions were significantly higher in AF participants (63.0% vs. 33.4% for 3:1 matched participants, p < 0.001). Non-CRC related findings on colonoscopy, like diverticulosis, were non-different between groups. Conclusion: Participants with AF had a higher burden of advanced premalignant adenomas and CRC in routine colonoscopy screening. Our data suggest that practitioners should monitor the CRC screening status, especially in AF patients. Full article
(This article belongs to the Special Issue New Approaches to the Atrial Fibrillation Management)
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Review

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Review
Stroke Prophylaxis in Patients with Atrial Fibrillation and End-Stage Renal Disease
J. Clin. Med. 2020, 9(1), 123; https://doi.org/10.3390/jcm9010123 - 02 Jan 2020
Cited by 2 | Viewed by 1267
Abstract
Atrial fibrillation (AF) is an important comorbidity in patients with end-stage renal disease (ESRD) undergoing dialysis that portends increased health care utilization, morbidity, and mortality in this already high-risk population. Patients with ESRD have a particularly high stroke risk, which is further compounded [...] Read more.
Atrial fibrillation (AF) is an important comorbidity in patients with end-stage renal disease (ESRD) undergoing dialysis that portends increased health care utilization, morbidity, and mortality in this already high-risk population. Patients with ESRD have a particularly high stroke risk, which is further compounded by AF. However, the role of anticoagulation for stroke prophylaxis in ESRD and AF is debated. The ESRD population presents a unique challenge because of the combination of elevated stroke and bleeding risks. Warfarin has been traditionally used in this population, but it is associated with significant risks of minor and major bleeding, particularly intracranial, thus leading many clinicians to forgo anticoagulation altogether. When anticoagulation is prescribed, rates of adherence and persistence are poor, leaving many patients untreated. The direct oral anticoagulants (DOACs) may offer an alternative to warfarin in ESRD patients, but these agents have not been extensively studied in this population and uncertainties regarding comparative effectiveness (versus warfarin, each other, and no treatment) remain. In this review, we discuss the current evidence on the risk and benefits of anticoagulants in this challenging population and comparisons between warfarin and DOACs, and review future directions including options for non-pharmacologic stroke prevention. Full article
(This article belongs to the Special Issue New Approaches to the Atrial Fibrillation Management)
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Review
Incidence, Management, Prevention and Outcome of Post-Operative Atrial Fibrillation in Thoracic Surgical Oncology
J. Clin. Med. 2020, 9(1), 37; https://doi.org/10.3390/jcm9010037 - 23 Dec 2019
Cited by 3 | Viewed by 1002
Abstract
Atrial fibrillation (AF) is a common supraventricular arrhythmia, a recognized risk factor for ischemic stroke, as a potential driver for heart failure (HF). Cancer patients have an increased risk for AF, even not including any cancer-specific treatment, as surgery or chemotherapy. The mechanism [...] Read more.
Atrial fibrillation (AF) is a common supraventricular arrhythmia, a recognized risk factor for ischemic stroke, as a potential driver for heart failure (HF). Cancer patients have an increased risk for AF, even not including any cancer-specific treatment, as surgery or chemotherapy. The mechanism is multifactorial, with inflammation and changes in autonomic tone as critical actors. Commonly, AF is a recurrent complication of the post-operative period in cancer surgery (especially thoracic). Recent papers confirmed a significant incidence of post-operative (non-cardiac surgery) AF (PAF), partially mitigated by the use of prophylactic (rate o rhythm control) treatments. A relevant difference, in terms of mean hospitalization time, emerges between patients developing PAF and those who do not, while long term impact remains a matter of debate, due to several potential confounding factors. Besides clinical predictors, structural (i.e., echocardiographic) and bio-humoral findings may help in risk prediction tasks. In this respect, pre-operative natriuretic peptides (NPs) concentrations are nowadays recognized as significant independent predictors of perioperative cardiovascular complications (including PAF), while elevated post-operative levels may further enhance risk stratification. The aim of the present paper is to trace the state of the art in terms of incidence, management, prevention, and outcome of PAF in the field of thoracic surgical oncology. Full article
(This article belongs to the Special Issue New Approaches to the Atrial Fibrillation Management)
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