Abstract nr. 1 Abstract code Hybrid Versus Catheter Ablation for Atrial Fibrillation: the HARTCAP-AF Trial

Transcription

1 Abstract nr. 1 Hybrid Versus Catheter Ablation for Atrial Fibrillation: the HARTCAP-AF Trial Auteur Vroomen, M., Maastricht University Medical Center, Maastricht, Nederland Co-auteur(s) - La Meir, M. Co-auteur(s) - Pison, L. Background: Although pulmonary vein isolation constitutes the cornerstone of interventional approaches for atrial fibrillation (AF), no uniform treatment in the setting of non-paroxysmal AF forms exists. Single procedural results of endocardial catheter ablation for (longstanding) persistent AF are disappointing and repeated procedures are often required. The combination of epicardial and endocardial (hybrid) ablation is expected to be most efficacious in avoiding lesion gaps. Currently, no robust clinical data comparing interventional treatment strategies in a randomized fashion are available. Purpose: The present study aims to compare hybrid ablation with catheter ablation regarding safety, efficacy and quality of life in patients with (longstanding) persistent AF. Methods Study Design: In this multi-center, prospective, randomized trial 236 consecutive patients with a history of symptomatic (longstanding) persistent AF will be included. The study consists of two arms: (1) repeated percutaneous endocardial catheter ablation within 6 months, versus (2) combined thoracoscopic surgical epicardial ablation and percutaneous endocardial catheter ablation. It is expected that a hybrid ablation is more effective in maintenance of sinus rhythm, and that it incorporates similar safety as catheter ablation in terms of major adverse events. The primary efficacy endpoint is freedom from any atrial tachyarrhythmia (AT) off antiarrhythmic drugs lasting > 5 minutes at 12 months after the last procedure. Secondary endpoints are complications, freedom from AT lasting > 30 seconds, freedom from AT after 36 months and quality of life, among others. Conlusion: The HARTCAP-AF trial investigates whether hybrid or (repeated) catheter ablation is superior in terms of efficacy, safety and quality of life in patients with non-paroxysmal AF.

2 Abstract nr. 3 Systematic analysis of ECG predictors for sinus rhythm maintenance following electrical cardioversion for persistent atrial fibrillation Auteur Lankveld, T.A.R., Maastricht University Medical Center, Maastricht, Nederland Co-auteur(s) - Vos, C.B. de Co-auteur(s) - Limantoro, I Co-auteur(s) - Zeemering, S. Co-auteur(s) - Dudink, E. Co-auteur(s) - Crijns, H.J.G.M. Co-auteur(s) - Schotten, U. Purpose: Electrical cardioversion (ECV) is one of the rhythm control strategies in patients with persistent atrial fibrillation (AF). Unfortunately, recurrences of AF are very common after ECV which significantly limits the practical benefit of this treatment in AF patients. The objective of this study was to identify non-invasive complexity or frequency parameters obtained from the surface electrocardiogram (ECG) to predict sinus rhythm (SR) maintenance after ECV and to compare these ECG-parameters with clinical predictors. Methods: We studied a large variety of ECG-derived time and frequency domain AF complexity parameters in a prospective cohort of 502 patients with persistent AF referred for ECV. We analysed the ECG recorded before ECV. Results: During 1 year follow-up 161 patients (32%) maintained SR. The best clinical predictor for SR maintenance was anti-arrhythmic drug (AAD) treatment. A model including clinical parameters predicted SR maintenance with a mean cross-validated receiver operator area under the curve (AUC) of 0.62 ± The best ECG-parameter was the dominant frequency (DF) on lead V6. Combining several ECG-parameters predicted SR maintenance with a mean AUC 0.64 ± Combining clinical and ECG-parameters improved prediction to a mean AUC 0.67 ± Although the DF was influenced by AAD treatment, excluding patients on AADs did not significantly lower the predictive performance captured by the ECG. Conclusions: ECG derived parameters predict SR maintenance during 1 year follow-up after ECV at least as good as known clinical predictors for rhythm outcome. The DF proved to be the most powerful ECG-derived predictor.

3 Abstract nr. 4 The Occurrence of Cardiovascular Disease in Apparently Idiopathic AF Patients and the Role of Early Cardiac CT Angiography, a 5-Year Follow-Up Study Auteur drs. Dudink, E.A.M.P., MUMC, Maastricht, Nederland Co-auteur(s) - Weijs, B. Co-auteur(s) - Haest, R.J. Co-auteur(s) - Kragten, J.A. Co-auteur(s) - Kietselaer, B.L. Co-auteur(s) - Wildberger, J.E. Co-auteur(s) - Crijns, H.J.G.M. PurposeIdiopathic atrial fibrillation (iaf) may be a first expression of vascular disease. The purpose of this study was to determine the incidence of cardiovascular disease (CVD) in patients originally diagnosed with iaf during 5 years of follow-up, and the association of the incidence of CVD with the presence of coronary artery disease (CAD) on baseline coronary CT angiography (CTA). MethodsBetween January 2008 and March 2011 we included all idiopathic paroxysmal AF patients who underwent CTA before catheter ablation. All patients were at baseline free of hypertension, diabetes, congestive heart failure, previous known coronary artery and peripheral vascular disease, previous stroke, thyroid, pulmonary, and renal disease, and had no structural abnormalities on echocardiography. Results115 patients with iaf (age 54.7 ± 10.1 years; 28.7% female) were included. During followup of 64 ± 8.3 months, CVD occurred in 26% of the patients and MACCE occurred in 6% of the patients. Unexpected subclinical CT angiographic CAD was present in 56 (49%) of the patients. Patients who developed CVD were significantly older and more often had CAD on CTA compared to those without CVD during follow-up (59.6 years and 52.8 years, p=0.001; 35.7% and 16.9%, p=0.02). The prevalence of soft plaques on CT was significantly higher in patients developing CVD than in those who do not (76.5% and 11.8%; p<0.001). Baseline characteristics were equal in those with CTA-CAD versus those without CTA-CAD. ConclusionsPatients originally diagnosed with iaf often develop CVD within 5 years of follow-up. Early CTA may help to identify those who are prone to develop CVD.

4 Abstract nr. 7 Improving patient selection for redo atrial fibrillation ablation - relation between left atrial remodeling and atrial fibrillation recurrence Auteur drs. Bhagirath, P., HAGA Teaching Hospital, The Hague, Nederland Co-auteur(s) - drs. Graaf, A.W.M. van der Co-auteur(s) - Driel, V.J.H.M. van Co-auteur(s) - Ramanna, H. Co-auteur(s) - Karim, R. Co-auteur(s) - Götte, M.J.W. Purpose:Patient selection for atrial fibrillation (AF) ablation is challenging. Conventionally used parameters poorly correlate to post-procedural AF recurrence. Recent investigations have reported left atrial sphericity (LASP) as an independent and strong predictor of index AF ablation success.this study investigated the utility of LASP in predicting AF recurrence following a redo ablation.methods:patients undergoing a first redo-ablation for symptomatic AF were included. Contrast enhanced computed tomography (CT) scans, acquired prior and post index ablation procedure, were used to create a left atrial segmentation. The LASP was computed using custommade software (figure 1). Results:25 patients (mean age 61 ± 8.4, 80% male) with paroxysmal (40%) and persistent (60%) AF were selected from a cohort of 54 patients. Fourteen patients (56%) had AF recurrence after the first redo-procedure.no relation was observed between nature (p=0.62) or duration of AF (p=0.51) and AF recurrence. There was no significant correlation between LA volumetric changes and AF recurrence.the change in LASP was significantly associated with AF recurrence (p<0.001). All patients with a positive change in LASP did not show AF recurrence during the follow-up (664 ± 245 days).conclusion:post-procedural changes in LASP following the index procedure correlate with outcome of redo catheter ablation procedures. Positive changes in the LASP, a surrogate for normalization of the geometry, are strongly associated with a higher success rate of the redo-procedure.patient selection for redo ablation could be improved by including geometrical remodeling as a stratification factor.

5 Computation of LA Sphericity

6 Abstract nr. 9 Atrial-paced atrioventricular delays in cardiac resynchronisation therapy can be easily optimized by utilizing intracardiac interelectrode delays Auteur Maass, A.H., UMC Groningen, Groningen, Nederland Co-auteur(s) - Kloosterman, M. Co-auteur(s) - Rienstra, M. Co-auteur(s) - Gelder, I.C. van Introduction: Cardiac resynchronisation therapy (CRT) is increasingly used in patients with heart failure and dyssynchrony or patients requiring permanent ventricular pacing. The SMART-AV trial questioned the benefit of atrioventricular delay optimization but has shown a potential benefit in patients with atrial pacing. It has been hypothesized that intracardiac signals can be used to find optimal AV delays. Methods: After recent CRT implantation, 315 consecutive patients, without permanent atrial fibrillation, were scheduled for AV delay optimization. 19 patients had atrial fibrillation during follow-up and were excluded. Optimal AV intervals were determined by echocardiography. Highest values of cardiac output by left ventricular outflow tract velocity time integrals and highest diastolic filling by mitral valve velocity time integrals were measured at different AV intervals with intrinsic conduction and atrial pacing at <10 beats above sinus rhythm. Intrinsic delay between right atrial (RA) and ventricular (RV) leads was measured at sinus rhythm and atrial pacing. Results: Optimal AV delays by echocardiography were 73±28ms at sinus rhythm and 147±32ms with atrial pacing. Intrinsic RA to RV delays showed no correlation with optimal programmed AV delays (R=0.26, p=0.67). Differences between optimal AV delays at intrinsic conduction and atrial pacing (74±18ms) were highly correlated with differences between intrinsic and paced AV (75±22ms) conduction (Bland-Altman difference 0ms, p<0.001). Conclusions: Optimal AV delays in CRT cannot be inferred from intrinsic RA to RV delays. The difference between intrinsic and paced AV delays can, however, be accurately measured by intracardiac signals. If empiric AV delays are used for intrinsic conduction, the difference between atrial sensed and paced AV delays can be easily calculated by intracardiac signals without the need for time-consuming echocardiographic measurements.

7 Abstract nr. 10 Cardiac resynchronization therapy without optimization is not an option. Auteur Saleem-Talib, S., Reinier de graaf gasthuis, Delft, Nederland Co-auteur(s) - Grauenkamp, C. Co-auteur(s) - Mechelen, R. van Co-auteur(s) - Scheffer, M.G. Background Cardiac resynchronization therapy (CRT) is a well-established therapy for patients with heart failure (HF). CRT optimization is essential since up to 40% of HF patients do not show any improvement of clinical status after CRT. The aim of our study is to show that echocardiographic optimization is crucial in both responders (R) and non-responders (NR). This will improve New York Heart Association (NYHA) class, left ventricular ejection fraction (LVEF), and reduce the amount of NR. Methods After CRT device implantation between , 350 patients, both NR and R who were referred for optimization, were included in this study. A protocol driven echocardiographic approach for adjusting mechanical dyssynchrony by adjusting V-V delay with strain and A-V delay with Doppler echocardiography was performed. The outcome was change in LVEF, NYHA class and the number of NR. Results: In 83% optimization was required. The V-V timing was adjusted in 61% and A-V timing in 51% respectively. In 3% the biventricular pacing was turned off and in 2,6. % LV only was programmed. LVEF after optimization showed an improvement of 6% in R and 9% in NR. The NYHA class scale improved significantly both in R and NR and the amount of NR was reduced to 16%. Conclusions: This is the first cohort study, which demonstrates that 83% of patients with a CRT device require CRT optimization after implantation in both R and NR. After optimization the NYHA class and LVEF improved significantly. The number of NR decreased to only 16%.