To Örebro University

OBJECTIVES: Minimally invasive surgical ablation for atrial fibrillation is an alternative to catheter ablation. Achieving lasting sinus rhythm in long-standing persistent atrial fibrillation is challenging and long-term data after surgery are limited. In 2016 we published a randomized trial comparing totally endoscopic box lesion ablation of the left atrium (case) to medical therapy (control) during one year in patients with long-standing persistent atrial fibrillation. This study presents data from a follow-up of our previous cohort to investigate the rhythm outcome long-term.

METHODS: This was an observational follow-up study. Most recent heart rhythm, time from totally endoscopic ablation to first relapse in atrial fibrillation, re-ablation, stroke, medication, left ventricular ejection fraction and mortality were gathered from medical records and analyzed with descriptive statistics and survival analysis.

RESULTS: At the end of the randomized trial, 80% of the cases had sinus rhythm without antiarrhythmic drugs. During a mean follow-up of 9 years, 43% of cases and 74% of controls had undergone additional ablation procedures (p = 0.009). At last follow-up 21% of cases and 5% of controls were in SR. After totally endoscopic ablation, mean time from surgery to first relapse in atrial fibrillation was 23 months (14-31 [95% CI] p <0.001).

CONCLUSIONS: In this population of patients with long-standing persistent atrial fibrillation, totally endoscopic box lesion ablation of the left atrium had short-term efficacy in restoring sinus rhythm. Long-term efficacy could not be demonstrated, with a high proportion of relapse in atrial fibrillation beyond one year post ablation.

Background: There is limited knowledge of physicians' antiarrhythmic drug (AAD) treatment practices for patients with atrial fibrillation and adherence to guidelines in European countries.

Methods: An online survey (n = 321) of cardiologists, cardiac electrophysiologists and interventional electrophysiologists was conducted in Germany (DE; n = 83), Italy (IT; n = 95), Sweden (SE; n = 60) and the United Kingdom (UK; n = 83) including 96 questions on treatment practices.

Results: ESC guidelines were the most important non-patient factor influencing treatment practice (55-72 %). However, while amiodarone was frequently (88-93 %) used in heart failure with reduced left ventricular ejection fraction, it was also a typical treatment choice for minimal/no-structural heart disease (SHD) (28 %), particularly in UK. Other deviations from guidelines were the use of class 1C drugs in coronary artery disease (CAD) and other SHD, and use of sotalol in left ventricular hypertrophy and renal impairment. In-hospital initiation of sotalol was low, with the exception of SE. Sotalol (16-41 %) and dronedarone use (10-54 %) in CAD varied among countries. For frequent, symptomatic paroxysmal AF, ablation was generally favoured, but AADs were preferred by 53 % in SE. In asymptomatic or subclinical AF, AADs were used by 41 % (range: 22-60 %), ablation by 11 % (range 2-18 %). In contrast to guidelines that prioritize safety, anticipated efficacy was more important (51 %) than safety (31 %) when selecting AADs.

Conclusions: Despite recognizing the importance of guidelines, deviations in AAD use were common with the potential to compromise patient safety. These findings indicate the need for more educational support for optimal AAD selection in AF management.

BACKGROUND: Atrial fibrillation is a common arrhythmia in patients with ischaemic heart disease. New-onset atrial fibrillation after coronary revascularisation is associated with adverse cardiovascular outcomes. This study aimed to determine the long-term cumulative incidence of new-onset atrial fibrillation after percutaneous coronary intervention or coronary artery bypass grafting surgery.

METHODS: A prospective observational cohort study in a real-world population setting, conducted at three tertiary centres, on new-onset atrial fibrillation incidence after percutaneous coronary intervention (N=123) or coronary artery bypass grafting (N=123). Heart rhythm was monitored the first 30 days in hospital by telemetry and on discharge using a handheld thumb ECG device three times a day, and thereafter for 2-week periods at 3, 12 and 24 months. The primary endpoint was the cumulative incidence of new-onset atrial fibrillation 24 months after the index procedure. Secondary objectives were to describe the incidence of cerebral ischaemic stroke and bleeding, myocardial infarction and major bleeding events during 24 months follow-up.

RESULTS: Mean age was 67 years, and male sex was more prevalent. At 30 days, the cumulative incidence of atrial fibrillation was 56% (69/123) in the coronary artery bypass graft group and 2% (3/123) in the percutaneous coronary intervention group. At 24 months, the cumulative incidence of atrial fibrillation was 58% (71/123) in the coronary artery bypass graft group and 6% (7/123) in the percutaneous coronary intervention group. Stroke, myocardial infarction and major bleeding were infrequent during follow-up.

CONCLUSION: Over 24 months of follow-up, incident new-onset atrial fibrillation mainly occurred during the first 30 days after coronary artery bypass grafting but was more evenly distributed during 24 months after percutaneous coronary intervention.

TRIAL REGISTRATION NUMBER: NCT04307225.

BACKGROUND: Atrial fibrillation (AF) is a rapidly increasing global public health concern entailing a high risk for ischemic stroke that can largely be avoided with anticoagulation therapy. AF is often underdiagnosed and there is a need for a reliable method of detection in individuals with additional risk factors for stroke such as coronary artery disease. We aimed to validate an automatic rhythm interpretation algorithm in thumb ECG in subjects with recent coronary revascularization.

METHODS: Thumb ECG, a patient-operated handheld single-lead ECG recording device with an automatic interpretation algorithm, was performed three times daily for a month after coronary revascularization and 2-week periods 3, 12, and 24 months post-procedure. The detection of AF by the automatic algorithm on subject and single-strip ECG level was compared to manual interpretation.

RESULTS: 48,308 of 30 s thumb ECG recordings from 255 subjects (mean 212 ± 3.5 recordings per subject) were retrieved from a database (AF 47 subjects/655 recordings; non-AF 208 subjects/47,653 recordings). The algorithm sensitivity at subject level was 100%, specificity 11.2%, positive predictive value (PPV) 20.2%, and negative predictive value (NPV) 100%. At the single-strip ECG level, sensitivity was 87.6%, specificity 94.0%, PPV 16.8%, and NPV 99.8%. The most common reasons for false positive results were technical disturbance and frequent ectopic beats.

CONCLUSIONS: The automatic interpretation algorithm in a handheld thumb ECG device can rule out AF in patients recently undergoing coronary revascularization with high accuracy, but manual confirmation is needed to confirm the diagnose of AF because of high false positive rates.

Background: We sought to determine the role of obesity in adolescent men on development of atrial fibrillation (AF) and subsequent associated clinical outcomes in subjects diagnosed with AF.

Methods and Results: We conducted a nationwide, register-based, cohort study of 1 704 467 men (mean age, 18.3±0.75 years) enrolled in compulsory military service in Sweden from 1969 through 2005. Height and weight, blood pressure, fitness, muscle strength, intelligence quotient, and medical disorders were recorded at baseline. Records obtained from the National Inpatient Registry and the Cause of Death Register were used to determine incidence and clinical outcomes of AF. During a median follow-up of 32 years (interquartile range, 24-41 years), 36 693 cases (mean age at diagnosis, 52.4±10.6 years) of AF were recorded. The multivariable-adjusted hazard ratio (HR) for AF increased from 1.06 (95% CI, 1.03-1.10) in individuals with body mass index (BMI) of 20.0 to <22.5 kg/m² to 3.72 (95% CI, 2.44-5.66) among men with BMI of 40.0 to 50.0 kg/m², compared with those with BMI of 18.5 to <20.0 kg/m². During a median follow-up of ≈6 years in patients diagnosed with AF, we identified 3767 deaths, 3251 cases of incident heart failure, and 921 cases of ischemic stroke. The multivariable-adjusted HRs for all-cause mortality, incident heart failure, and ischemic stroke in AF-diagnosed men with baseline BMI >30 kg/m² compared with those with BMI <20 kg/m² were 2.86 (95% CI, 2.30-3.56), 3.42 (95% CI, 2.50-4.68), and 2.34 (95% CI, 1.52-3.61), respectively.

Conclusions: Increasing BMI in adolescent men is strongly associated with early AF, and with subsequent worse clinical outcomes in those diagnosed with AF with respect to all-cause mortality, incident heart failure, and ischemic stroke.

Catheter ablation for treatment of atrial fibrillation (AF), AF ablation, is more effective than antiarrhythmic drugs in reducing AF burden, reducing symptoms and increasing health-related quality of life. Although females more often experience AF-related symptoms, and have more severe symptoms, have lower quality of life, and experience more serious adverse effects of antiarrhythmic drugs than males, they are less likely to undergo AF ablation. Potential explanations for the disparity include older age at diagnosis, longer AF duration, a greater number of comorbidities, more extensive atrial fibrosis, and presumed lower success rate and more complications after AF ablation in women. Studies have failed to show sex-related differences in AF recurrence or serious complications following AF ablation but show more nuisance bleeds in women. Ethnic minorities, such as African Americans and Latin Americans, and individuals of low socioeconomic status are also less likely to undergo AF ablation, possibly associated with greater numbers of comorbidities, lack of patient advocacy, healthcare costs, and inadequate insurance coverage. Inclusion of marginalized patient groups in clinical trials of AF treatment and a personalized, patient-centered approach may expand equality in utilization of AF ablation.

Introduction: Atrial fibrillation (AF) is associated with an increased risk of stroke, heart failure and cardiovascular death. Initial treatment focuses on rhythm or rate control and anticoagulation after risk assessment. Catheter abla-tion (CA) is an option in highly symptomatic patients but is less effective in long-standing persistent AF(LSPAF). Total endoscopic ablation is an alternative, but its clinical role needs further evaluation. In patients undergoing aortocoronary bypass graft (CABG) surgery, up to 9 % present with preoperative AF. One-third experience postoperative AF, which is associated with increased hospital stay, risk of stroke and decreased long-term survival. The long-term effects on heart rhythm have not been studied.

Methods and Results: 571 patients undergoing CABG from 1999 to 2000 were followed for six years. Postoperative AF was the strongest independent risk factor for late AF and an age-independent risk factor for late mortality. 615 pa-tients from the same cohort, including patients with preoperative AF, were fol-lowed up at 15 years. Death due to cerebral ischaemia, heart failure and sudden death were most common in the pre- and postoperative AF groups. The presence of pre- or postoperative AF was an independent risk factor for late mortality.

In our first ten patients, total endoscopic ablation of AF using a right-sided unilateral approach was feasible and safe with acceptable results. 36 patients with symptomatic LSPAF were then randomized to total endoscopic ablation or rate control. Loop recorders were implanted in all patients. In the control group, all patients were in permanent AF for 12 months. In the ablation group, 12/15 patients (80%) were in SR without antiarrhythmic drugs at 12 months. Median freedom of AF at 3–12 months was 95%, and 8/15 (53%) had an AF burden of < 5%. Myocardial function, physical working capacity(PWC) and subjective physical and mental health improved.

Conclusions: Postoperative AF patients have an eightfold increased risk of future AF and a doubled long-term cardiovascular mortality. Both pre- or post-operative AF in CABG patients is a major risk factor for late cardiovascular morbidity and mortality. Total endoscopic ablation of AF is feasible and safe. In patients with LSPAF, it significantly reduced AF burden at 12 months compared with controls. Myocardial function, PWC and subjective physical and mental health improved.

Objectives: To study pre- and postoperative atrial fibrillation and its long-term effects in a cohort of aortocoronary bypass surgery patients.

Design: Altogether 615 patients undergoing aortocoronary bypass graft surgery in 1999-2000 were studied. Forty-four (7%) had preoperative atrial fibrillation. Postoperative atrial fibrillation occurred in 165/615 patients (27%) while 406/615 patients (66%) had no atrial fibrillation. After a median follow-up of 15 years, symptoms and medication in survivors were recorded, and cause of death in the deceased was obtained.

Results: Death due to cerebral ischaemia was most common in the pre- and postoperative atrial fibrillation groups (7% and 5%, respectively, v. 2% among those without atrial fibrillation, p = 0.038), as were death due to heart failure (18% and 14%, v. 7%, p = 0.007) and sudden death (9% and 5%, v. 2%, p = 0.029). The presence of pre- or postoperative atrial fibrillation was an independent risk factor for late mortality (hazard ratios 1.47 (1.02-2.12) and 1.28 (1.01-1.63), respectively).

Conclusions: Patients with pre- or postoperative atrial fibrillation undergoing aortocoronary bypass surgery have increased long-term mortality and risk of cerebral ischemic and cardiovascular death compared with patients in sinus rhythm.

Objectives: Total endoscopic ablation of atrial fibrillation is an alternative to catheter ablation, but its clinical role needs further evaluation. The aim of this study was to compare total endoscopic ablation with rate control in patients with long-standing persistent atrial fibrillation and to examine the effect of endoscopic ablation on heart rhythm, symptoms, physical working capacity and myocardial function during 1 year of follow-up.

Methods: In a prospective controlled study, 36 patients aged >50 years with symptomatic long-standing persistent atrial fibrillation were randomized to either total endoscopic ablation (n = 17, after two drop-outs before ablation n = 15) or rate control therapy (n = 19). In the ablation group, a box lesion encircling the pulmonary veins was performed, using temperature-controlled radiofrequency energy. Loop recorders were implanted in all patients. Echocardiography and quality-of-life assessment were performed at 6 and 12 months, and physical working capacity assessment at 6 months.

Results: There was no mortality or thromboembolic event. In the control group, all patients were in permanent atrial fibrillation during 12 months of follow-up. In the ablation group, the proportion of patients in sinus rhythm without antiarrhythmic drugs was 12/15 (80%) at 12 months. The median freedom of atrial fibrillation at 3-12 months was 95% in the ablation group and the proportion of patients with an atrial fibrillation burden of <5% at 3-12 months was 8/15 (53%). The left ventricular ejection fraction increased during follow-up in the ablation group compared with the control group (from 53.7 ± 8.6 to 58.8 ± 6.5%, P = 0.003), combined with a reduction in the left atrial area (from 29.2 ± 5.5 to 27.2 ± 6.3 cm(2), P = 0.002). The physical working capacity increased in the ablation group compared with the control group (from 94 ± 21.4 to 102.9 ± 14.4%, P = 0.011). The subjective physical and mental capacity scale also improved during follow-up in the ablation group, but not in the control group (P =0.003 and 0.018, respectively).

Conclusions: Total endoscopic ablation in patients with long-standing persistent atrial fibrillation significantly reduced atrial fibrillation burden 12 months after intervention compared with controls. The left ventricular function, physical working capacity and subjective physical and mental health were improved. These results need to be confirmed in larger randomized trials.

Total endoscopic ablation of atrial fibrillation is a treatment option in symptomatic patients after unsuccessful catheter ablation or when catheter ablation is considered inappropriate. We describe a technique of endoscopic ablation of the left atrium using temperature-controlled unipolar or bipolar radiofrequency. A left atrial box lesion encircling the pulmonary veins is created using three ports in the right hemithorax. The technical aspects and preliminary results of the procedure are discussed.