Publications by authors named "Jason Andrade"

165 Publications

Prevalence and Outcome of Early Recurrence of Atrial Tachyarrhythmias in the Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation (CIRCA-DOSE) Study.

Heart Rhythm 2021 Jun 11. Epub 2021 Jun 11.

Heart Rhythm Services, Department of Medicine, University of British Columbia, Canada; Center for Cardiovascular Innovation, Vancouver, Canada; Montreal Heart Institute, Department of Medicine, Université de Montréal, Canada. Electronic address:

Background: Early recurrence of atrial tachyarrhythmia (ERAT) is common after pulmonary vein isolation (PVI) and has been associated with an increased risk of late AF recurrence.

Objective: We sought to determine the incidence and outcomes of patients experiencing ERAT after PVI using advanced-generation ablation technologies.

Methods: This is a prespecified substudy of the CIRCA-DOSE trial, a prospective, randomized, multicenter study comparing PVI with contact force-guided radiofrequency ablation to secondary-generation cryoballoon ablation for paroxysmal AF. All study patients received an implantable cardiac monitor to allow continuous rhythm monitoring. ERAT was defined as any recurrent atrial tachyarrhythmia within the first 90 days after AF ablation.

Results: ERAT occurred in 61% of the 346 patients at a median of 12 days (range 1-90 days) after ablation. ERAF was a significant predictor of late recurrence (60.1% with ER vs 25.9% without ER;p<0.001) and symptomatic atrial tachyarrhythmia (31.6% with ERAF vs. 6.7% without ERAF;p<0.001). Receiver operating curve analyses revealed a strong correlation between ERAF timing and burden and late recurrence. Multivariate analysis identified ER timing (HR 2.90; 95%CI1.41-5.95;p=0.004) and burden (HR 1.05 per 1% ER burden, 95%CI1.04-1.07;p<0.001) as strong independent predictors of late recurrence. The incidence rate, timing, burden, and prognostic significance of ER did not differ between the study groups.

Conclusions: Early recurrence of atrial tachyarrhythmia remains common after PVI despite use of advanced-generation ablation technologies. Early AF recurrence beyond 3 weeks after ablation is associated with increased risk of late recurrence.
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http://dx.doi.org/10.1016/j.hrthm.2021.06.1172DOI Listing
June 2021

Effectiveness of a simple medication adjustment protocol for optimizing peri-cardioversion rate control: A derivation and validation cohort study.

Heart Rhythm O2 2021 Feb 12;2(1):46-52. Epub 2021 Jan 12.

Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada.

Background: Rate control medications are foundational in the management of persistent atrial fibrillation (AF). There are no guidelines for adjusting these medications prior to elective direct-current cardioversion (DCCV).

Objective: To derive and validate a preprocedural medication adjustment protocol that maintains peri-DCCV rate control and minimizes risk of postconversion bradycardia, pauses, need for pacing, and cardiopulmonary resuscitation (CPR).

Methods: Consecutive patients with persistent AF awaiting elective DCCV across 2 hospitals were screened for inclusion into derivation, validation, and control cohorts. In the derivation cohort, each patient taking an atrioventricular (AV) nodal blocker had medications adjusted based on heart rate (HR) 2 days before DCCV, and the magnitude of dose adjustment was compared with peri-DCCV HR. The adjustment protocol that achieved the highest percentage of optimal peri-DCCV rate control was tested prospectively in the validation cohort and compared to a standard-of-care control group.

Results: The optimal protocol from the derivation cohort (n = 71), based on the 2-day pre-DCCV HR, was to (1) CONTINUE AV nodal blocker for HR ≥ 100 beats per minute (bpm), (2) reduce dose by ONE increment when 80-99 bpm, (3) reduce dose by TWO increments when 60-79 bpm, and (4) HOLD when <60 bpm. In the prospective validation cohort (n = 106), this protocol improved peri-DCCV rate control (82% vs 62%, < .001) compared to current standard of care (n = 107). There were no conversion pauses ≥5 seconds, need for pacing, or CPR post-DCCV.

Conclusion: This simple preprocedural medication adjustment protocol provides an effective strategy of optimizing peri-DCCV rate control in patients with AF.
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http://dx.doi.org/10.1016/j.hroo.2021.01.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183961PMC
February 2021

Cryoablation for atrial fibrillation.

Authors:
Jason G Andrade

Heart Rhythm O2 2020 Apr 27;1(1):44-58. Epub 2020 Apr 27.

Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada.

Cryoballoon ablation for the treatment of atrial fibrillation has established itself as an effective and efficient modality for achieving pulmonary vein isolation. Over the past 13 years more than 100,000 Cryoballoon ablation procedures have been performed with the first to fourth generation cryoballoons. Over that time there have been significant advances in our understanding regarding the optimal procedural techniques. The purpose of this "topic in review" is to focus on the practical aspects of performing a Cryoballoon ablation procedure, within the context of the contemporary literature. Specifically there is a focus on how contemporary studies can inform clinical decision making and ensure operators are able to perform a safe and effective procedure.
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http://dx.doi.org/10.1016/j.hroo.2020.02.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183843PMC
April 2020

Cryoablation as Initial Therapy for Atrial Fibrillation. Reply.

N Engl J Med 2021 05;384(21):e82

Southlake Regional Health Center, Newmarket, ON, Canada.

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http://dx.doi.org/10.1056/NEJMc2103408DOI Listing
May 2021

Response to letter to the Editor CJC-D-21-00657R1.

Can J Cardiol 2021 May 17. Epub 2021 May 17.

Montreal Heart Institute, Department of Medicine, Université de Montréal, Canada.

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http://dx.doi.org/10.1016/j.cjca.2021.05.005DOI Listing
May 2021

Size matters in atrial fibrillation: the underestimated importance of reduction of contiguous electrical mass underlying the effectiveness of catheter ablation.

Europace 2021 May 5. Epub 2021 May 5.

Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada.

Evidence has accumulated over the last century of the importance of a critical electrical mass in sustaining atrial fibrillation (AF). AF ablation certainly reduces electrically contiguous atrial mass, but this is not widely accepted to be an important part of its mechanism of action. In this article, we review data showing that atrial size is correlated in many settings with AF propensity. Larger mammals are more likely to exhibit AF. This is seen both in the natural world and in animal models, where it is much easier to create a goat model than a mouse model of AF, for example. This also extends to humans-athletes, taller people, and obese individuals all have large atria and are more likely to exhibit AF. Within an individual, risk factors such as hypertension, valvular disease and ischaemia can enlarge the atrium and increase the risk of AF. With respect to AF ablation, we explore how variations in ablation strategy and the relative effectiveness of these strategies may suggest that a reduction in electrical atrial mass is an important mechanism of action. We counter this with examples in which there is no doubt that mass reduction is less important than competing theories such as ganglionated plexus ablation. We conclude that, when considering future strategies for the ablative therapy of AF, it is important not to discount the possibility that contiguous electrical mass reduction is the most important mechanism despite the disappointing consequence being that enhancing success rates in AF ablation may involve greater tissue destruction.
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http://dx.doi.org/10.1093/europace/euab078DOI Listing
May 2021

Anticoagulation management of postoperative atrial fibrillation after cardiac surgery: A systematic review.

J Card Surg 2021 Jun 26;36(6):2081-2094. Epub 2021 Mar 26.

Division of Cardiovascular Surgery, University of British Columbia, Vancouver, British Columbia, Canada.

Background: Postoperative atrial fibrillation (POAF) often complicates cardiac surgery and is associated with increased mortality and risk of thromboembolism. However, the optimal oral anticoagulation (OAC) strategy is uncertain. We performed a systematic review to examine the OAC practice patterns and efficacy in these circumstances.

Methods: MEDLINE and EMBASE were searched from 2000 to 2019 using the search terms cardiac surgical procedures, cardiac surgery, postoperative complications, atrial fibrillation, atrial flutter, and terms for anticoagulants. Collected data included anticoagulation patterns (time of initiation, type, and duration) and outcomes (stroke, bleeding, and mortality).

Results: From 763 records, 4 prospective and 13 retrospective studies were included totaling 44,908 patients with 8929 (19.9%) who developed POAF. Anticoagulation rates ranged from 4% to 43% (mean 21% overall). Sixteen studies used warfarin, 3 nonvitamin K OAC (NOAC), and 2 both. Four studies reported the use of bridging unfractionated or low-molecular-weight heparin. Concomitant antiplatelet therapy was reported in half the studies, ranging from 80% to 99%. OAC use was associated with lower risk of thromboembolic events in two retrospective studies (including a national Danish cohort with 2108 patients with POAF). Patients discharged on warfarin experienced reduced mortality in a large, single center, retrospective analysis, but no association was observed in the Danish cohort.

Conclusion: There is wide practice variation in the uptake, timing of initiation, duration, and choice of OAC for POAF following cardiac surgery. The evidence is largely retrospective and insufficient to assess the efficacy of different OAC strategies. Further studies are warranted to guide clinical practice.
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http://dx.doi.org/10.1111/jocs.15396DOI Listing
June 2021

Validity of different dose reduction criteria for apixaban.

Am Heart J 2021 Mar 21;238:12-15. Epub 2021 Mar 21.

Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.

Reduced-dose apixaban is recommended in patients fulfilling 2 of 3 criteria: age ≥80 years, body weight ≤60 kg, and serum creatinine ≥1.5 mg/dL. However, patient weight is often not available in electronic health data. We examined the validity of alternative definitions based on age and renal function alone using an observational dataset of patients with atrial fibrillation and chronic kidney disease which included weight measurements.
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http://dx.doi.org/10.1016/j.ahj.2021.03.004DOI Listing
March 2021

Autonomic Alterations After Pulmonary Vein Isolation in the CIRCA-DOSE (Cryoballoon vs Irrigated Radiofrequency Catheter Ablation) Study.

J Am Heart Assoc 2021 Feb 26;10(5):e018610. Epub 2021 Feb 26.

Center for Cardiovascular Innovation Vancouver Canada.

Background The natural history of autonomic alterations following catheter ablation of drug-refractory paroxysmal atrial fibrillation is poorly defined, largely because of the historical reliance on non-invasive intermittent rhythm monitoring for outcome ascertainment. Methods and Results The study included 346 patients with drug-refractory paroxysmal atrial fibrillation undergoing pulmonary vein isolation using contemporary advanced-generation ablation technologies. All patients underwent insertion of a Reveal LINQ (Medtronic) implantable cardiac monitor before ablation. The implantable cardiac monitor continuously recorded physical activity, heart rate variability (measured as the SD of the average normal-to-normal), daytime heart rate, and nighttime heart rate. Longitudinal autonomic data in the 2-month period leading up to the date of ablation were compared with the period from 91 to 365 days following ablation. Following ablation there was a significant decrease in SD of the average normal-to-normal (mean difference versus baseline of 19.3 ms; range, 12.9-25.7; <0.0001), and significant increases in daytime and nighttime heart rates (mean difference versus baseline of 9.6 bpm; range, 7.4-11.8; <0.0001, and 7.4 bpm; range, 5.4-9.3; <0.0001, respectively). Patients free of arrhythmia recurrence had significantly faster daytime (11±11 versus 8±12 bpm, =0.001) and nighttime heart rates (8±9 versus 6±8 bpm, =0.049), but no difference in SD of the average normal-to-normal (=0.09) compared with those with atrial fibrillation recurrence. Ablation technology and cryoablation duration did not influence these autonomic nervous system effects. Conclusions Pulmonary vein isolation results in significant sustained changes in the heart rate parameters related to autonomic function. These changes are correlated with procedural outcome and are independent of the ablation technology used. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01913522.
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http://dx.doi.org/10.1161/JAHA.120.018610DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174287PMC
February 2021

Real world Data on the Concurrent Use of P-glycoprotein or Cytochrome 3A4 Drugs and Non-vitamin K Antagonist Oral Anticoagulants in Non-Valvular Atrial Fibrillation.

Eur Heart J Qual Care Clin Outcomes 2021 Jan 22. Epub 2021 Jan 22.

Division of Cardiology, University of Alberta, Edmonton, Canada.

Aim: To determine the concurrent use of P-glycoprotein (P-gp) or Cytochrome (CYP) 3A4 drugs and non-vitamin K antagonist oral anticoagulants (NOACs) among non-valvular AF (NVAF) patients in clinical practice.

Methods And Results: Administrative databases identified all adults (≥ 18 years) with incident or prevalent NVAF who initiated a NOAC in an outpatient or inpatient setting, between July 2012-March 2019 in Alberta, Canada. Concurrent use was defined as a P-gp or CYP3A4 dispensation in the 100 days prior to and overlapping NOAC dispensation. The P-gp and CYP3A4 drugs were categorized into 3 groups and drug-drug interactions classified according to the 2018 European Heart Rhythm Association practical guide. Time-varying Cox models calculated crude hazard ratio (HR) of outcomes at 1-year. A total of 642,255 NOAC dispensations occurred for 36,566 NVAF patients. Of these, 71,643 (11.2%) had a concurrent dispensation of an interacting P-gp or CYP3A4 drug. Overall, the drug-drug interaction was defined as contraindicated in 2.5%, avoid/caution in 2.3%, and for another 6.7% should require a dose adjustment. When all drug-drug interactions were considered, inappropriate NOAC prescribing occurred in 63% (n = 45,080) of dispensations. There was a significantly higher risk of death (HR 1.58, 1.47-1.70) for a drug-drug interaction but not for stroke (p = 0.89) or major bleeding risk (p = 0.13).

Conclusions: The concurrent use of P-gp or CYP3A4 drugs and NOACs was uncommon but important since almost two-thirds of patients with drug-drug interactions had inappropriate NOAC dosing and a higher risk of death. More attention to this issue is needed.
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http://dx.doi.org/10.1093/ehjqcco/qcab002DOI Listing
January 2021

Chronic Amiodarone Use and the Risk of Cancer: A Systematic Review and Meta-analysis.

CJC Open 2021 Jan 17;3(1):109-114. Epub 2020 Sep 17.

Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

Background: Observational studies have identified inconsistent associations between chronic use of amiodarone and cancer-related outcomes. We performed a systematic review and meta-analysis to evaluate cancer risk among patients receiving amiodarone.

Methods: We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) to May 1, 2020. We included randomized controlled trials (RCTs) with follow-up ≥2 years that compared amiodarone (any dose) to any comparator (placebo, active pharmacologic or interventional comparator, or usual care), and reported ≥1 outcome of interest. We contacted authors of published chronic amiodarone trials for potentially unreported cancer outcomes. The primary outcome was cancer incidence. Secondary outcomes were cancer-related death and site-specific cancers. We determined risk ratios and 95% confidence intervals using a fixed-effect model, and statistical heterogeneity using . We conducted prespecified subgroup and sensitivity analyses for amiodarone indication, amiodarone dose, duration of therapy, and trial-level risk of bias.

Results: From 1439 articles, we included 5 RCTs (n = 4357). Mean follow-up duration ranged from 21 to 37 months. We included previously unpublished cancer outcome data from 1 RCT. Our primary outcome was not reported in any RCT. There was no significant difference in cancer-related death between amiodarone (1.69%) and the comparator (1.75%) (risk ratio 0.96, 95% confidence interval 0.57-1.63;  = 0%). There were no significant interactions from our subgroup or sensitivity analyses.

Conclusions: Chronic amiodarone use did not increase cancer-related deaths. Data from RCTs do not support an increased risk of cancer-related harms with amiodarone use, and these concerns should not deter use of amiodarone when indicated.
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http://dx.doi.org/10.1016/j.cjco.2020.09.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7801211PMC
January 2021

Anticoagulation for Patients With Atrial Fibrillation and End-Stage Renal Disease on Dialysis: A National Survey.

Can J Cardiol 2020 Dec 10. Epub 2020 Dec 10.

Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Patients with atrial fibrillation (AF) have a significant increased risk of embolic stroke. Patients with end-stage renal disease who are on dialysis have an increased risk of both embolic stroke and bleeding. Stroke-prevention studies with the use of anticoagulation for AF patients have excluded patients on dialysis, so there remains no consensus on their management. We developed and implemented a pan-Canadian multidisciplinary survey to explore the current beliefs and practices concerning patients with AF on dialysis. We developed an online investigator-designed survey with both quantitative and qualitative responses with the use of a secure university-affiliated electronic service. The survey was distributed to physicians via the QxMD platform and directly to internal medicine, cardiology, and nephrology residency program directors for distribution to faculty members. 130 participants responded, including 46 cardiologists, 45 nephrologists, 30 general internists, and 9 other physicians. The preferred anticoagulant was warfarin. The CHADS score used to initiate anticoagulation was highly variable, with specialties differing in use of a CHADS threshold of ≥ 1 (P < 0.001) and the impact of previous transient ischemic attack/stroke (P = 0.02). Calciphylaxis history affected the decision to prescribe anticoagulation. Specialties differed in thresholds used to consider direct oral anticoagulants for dialysis patients, with nephrologists more likely to prescribe anticoagulation at higher CHADS scores. Our survey demonstrated significant heterogeneity of anticoagulation use for stroke prevention in patients with AF on dialysis. Physician specialty and patient risk profiles contributed to the observed variability. This study reemphasises the need for clinical trials, large observational studies, and consensus guidelines to address evident equipoise.
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http://dx.doi.org/10.1016/j.cjca.2020.12.005DOI Listing
December 2020

Cryoablation or Drug Therapy for Initial Treatment of Atrial Fibrillation.

N Engl J Med 2021 01 16;384(4):305-315. Epub 2020 Nov 16.

From Vancouver General Hospital (J.G.A., M.B.), the University of British Columbia (J.G.A., M.W.D., M.B., S.L.), and the Centre for Cardiovascular Innovation (J.G.A., M.W.D.), Vancouver, Montreal Heart Institute, Université de Montréal (J.G.A., L.M.) and McGill University Health Centre (V.E.), Montreal, the University of Ottawa Heart Institute, Ottawa (G.A.W.), Université Laval, Quebec, QC (J.C.), Université de Sherbrooke, Sherbrooke, QC (J.-F.R.), Rouge Valley Centenary Hospital, Scarborough, ON (D.Y.), Western University, London, ON (A.S.), Southlake Regional Health Centre, University of Toronto, Newmarket, ON (Y.K., A.V.), Libin Cardiovascular Institute, University of Calgary, Calgary, AB (C.M.), St. Mary's General Hospital, Kitchener, ON (U.J.), Royal Jubilee Hospital, Victoria, BC (P.N.), Royal Alexandra Hospital, Edmonton, AB (E.L.), McMaster University, Hamilton, ON (G.A.), St. Michael's Hospital, University of Toronto, Toronto (P.A.), Dalhousie University, Halifax, NS (J.S.), and the University of Saskatchewan, Saskatoon, SK (S.W.) - all in Canada.

Background: Guidelines recommend a trial of one or more antiarrhythmic drugs before catheter ablation is considered in patients with atrial fibrillation. However, first-line ablation may be more effective in maintaining sinus rhythm.

Methods: We randomly assigned 303 patients with symptomatic, paroxysmal, untreated atrial fibrillation to undergo catheter ablation with a cryothermy balloon or to receive antiarrhythmic drug therapy for initial rhythm control. All the patients received an implantable cardiac monitoring device to detect atrial tachyarrhythmia. The follow-up period was 12 months. The primary end point was the first documented recurrence of any atrial tachyarrhythmia (atrial fibrillation, atrial flutter, or atrial tachycardia) between 91 and 365 days after catheter ablation or the initiation of an antiarrhythmic drug. The secondary end points included freedom from symptomatic arrhythmia, the atrial fibrillation burden, and quality of life.

Results: At 1 year, a recurrence of atrial tachyarrhythmia had occurred in 66 of 154 patients (42.9%) assigned to undergo ablation and in 101 of 149 patients (67.8%) assigned to receive antiarrhythmic drugs (hazard ratio, 0.48; 95% confidence interval [CI], 0.35 to 0.66; P<0.001). Symptomatic atrial tachyarrhythmia had recurred in 11.0% of the patients who underwent ablation and in 26.2% of those who received antiarrhythmic drugs (hazard ratio, 0.39; 95% CI, 0.22 to 0.68). The median percentage of time in atrial fibrillation was 0% (interquartile range, 0 to 0.08) with ablation and 0.13% (interquartile range, 0 to 1.60) with antiarrhythmic drugs. Serious adverse events occurred in 5 patients (3.2%) who underwent ablation and in 6 patients (4.0%) who received antiarrhythmic drugs.

Conclusions: Among patients receiving initial treatment for symptomatic, paroxysmal atrial fibrillation, there was a significantly lower rate of atrial fibrillation recurrence with catheter cryoballoon ablation than with antiarrhythmic drug therapy, as assessed by continuous cardiac rhythm monitoring. (Funded by the Cardiac Arrhythmia Network of Canada and others; EARLY-AF ClinicalTrials.gov number, NCT02825979.).
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http://dx.doi.org/10.1056/NEJMoa2029980DOI Listing
January 2021

The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation.

Can J Cardiol 2020 12 22;36(12):1847-1948. Epub 2020 Oct 22.

Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.

The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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http://dx.doi.org/10.1016/j.cjca.2020.09.001DOI Listing
December 2020

Pulmonary Vein Stenosis After Atrial Fibrillation Ablation: Insights From the ADVICE Trial.

Can J Cardiol 2020 12 3;36(12):1965-1974. Epub 2020 Nov 3.

Montreal Health Innovations Coordinating Center (MHICC), Montreal, Quebec, Canada.

Background: Pulmonary vein (PV) stenosis is a complication of atrial fibrillation (AF) ablation. The incidence of PV stenosis after routine post-ablation imaging remains unclear and is limited to single-centre studies. Our objective was to determine the incidence and predictors of PV stenosis following circumferential radiofrequency ablation in the multicentre Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination (ADVICE) trial.

Methods: Patients with symptomatic AF underwent circumferential radiofrequency ablation in one of 13 trial centres. Computed tomographic (CTA) or magnetic resonance (MRA) angiography was performed before ablation and 90 days after ablation. Two blinded reviewers measured PV diameters and areas. PVs with stenosis were classified as severe (> 70%), moderate (50%-70%), or mild (< 50%). Predictors of PV stenosis were identified by means of multivariable logistic regression.

Results: A total of 197 patients (median age 59.5 years, 29.4% women) were included in this substudy. PV stenosis was identified in 41 patients (20.8%) and 47 (8.2%) of 573 ablated PVs. PV stenosis was classified as mild in 42 PVs (7.3%) and moderate in 5 PVs (0.9%). No PVs had severe stenosis. Both cross-sectional area and diameter yielded similar classifications for severity of PV stenosis. Diabetes was associated with a statistically significant increased risk of PV stenosis (OR 4.91, 95% CI 1.45-16.66).

Conclusions: In the first systematic multicentre evaluation of post-ablation PV stenosis, no patient acquired severe PV stenosis. Although the results are encouraging for the safety of AF ablation, 20.8% of patients had mild or moderate PV stenosis, in which the long-term effects are unknown.
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http://dx.doi.org/10.1016/j.cjca.2020.10.013DOI Listing
December 2020

The Canadian Cardiovascular Society Atrial Fibrillation Guidelines Program: A Look Back Over the Last 10 Years and a Look Forward.

Can J Cardiol 2020 12 7;36(12):1839-1842. Epub 2020 Oct 7.

Montréal Heart Institute, University of Montréal, Montréal, Québec, Canada.

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http://dx.doi.org/10.1016/j.cjca.2020.10.001DOI Listing
December 2020

Impact of Female Sex on Clinical Presentation and Ablation Outcomes in the CIRCA-DOSE Study.

JACC Clin Electrophysiol 2020 08 29;6(8):945-954. Epub 2020 Jul 29.

Heart Rhythm Services, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada. Electronic address:

Objectives: This study sought to evaluate sex-specific differences in atrial fibrillation (AF) presentation and catheter ablation outcomes in the prospective, multicenter, randomized CIRCA-DOSE (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation: Double Short vs. Standard Exposure Duration) study.

Background: Similar to other cardiovascular conditions, significant sex-specific differences have been observed in the epidemiology, pathophysiology, presentation, and natural history of AF. Unfortunately, there are major gaps in our understanding of the pathophysiological basis for the observed sex-specific differences and their implications on therapy and prognosis.

Methods: This study examined sex-specific differences in AF presentation, symptom severity and health-related quality of life, symptomatic and asymptomatic arrhythmia recurrence, AF burden, and health care utilization.

Results: Freedom from any atrial tachyarrhythmia and symptomatic atrial tachyarrhythmia were similar between male (hazard ratio: 1.18; 95% confidence interval: 0.85 to 1.64; p = 0.39) and female patients (hazard ratio: 1.00; 95% confidence interval: 0.62 to 1.59; p = 0.92). Post-ablation, the median AF burden (percentage time in AF) was 0.00% (interquartile range: 0.00% to 0.16%) in male patients and 0.00% (interquartile range: 0.00% to 0.17%) in female patients, with no difference observed between the sexes (p = 0.30). Periprocedural complications occurred twice as frequently in female patients (3.5% vs. 7.0%; p = 0.18). In comparison to male patients, female patients reported a significantly worse symptom score and quality of life at baseline and all follow-up intervals, but they derived similar magnitude of improvement post-ablation. There was no difference between male and female patients with respect to emergency department visits, hospitalization, cardioversion, or repeat ablation.

Conclusions: When compared with male patients, female patients have significantly worse symptom scores and quality of life at baseline. Despite this, female patients with symptomatic paroxysmal AF derive similar benefit in freedom from recurrent arrhythmia and similar improvements in quality of life following AF ablation. (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation: Double Short vs. Standard Exposure Duration [CIRCA-DOSE]; NCT01913522).
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http://dx.doi.org/10.1016/j.jacep.2020.04.032DOI Listing
August 2020

Quality of Life and Health Care Utilization in the CIRCA-DOSE Study.

JACC Clin Electrophysiol 2020 08;6(8):935-944

Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada; Montreal Health Innovations Coordinating Centre, Montreal, Québec, Canada.

Objectives: This study evaluated the impact of contact force-guided radiofrequency ablation versus cryoballoon ablation on quality of life and health care utilization.

Background: Traditional outcome parameters, such as arrhythmia-free survival, are insufficient to evaluate the clinical impact of atrial fibrillation (AF), as it fails to the capture patient- and health system-level differences in treatment approaches.

Methods: The CIRCA-DOSE (Cryoballoon Vs. Contact-Force Atrial Fibrillation Ablation) study randomly assigned 346 patients with drug-refractory paroxysmal AF to contact force-guided radiofrequency or cryoballoon ablation. Health-related quality-of-life (HRQOL) was assessed at baseline, and at 6 and 12 months post-ablation using a disease-specific and generic HRQOL instruments. Health care utilization (hospitalization, emergency department visits, and cardioversion) and antiarrhythmic drug use for the 12 months preceding ablation was compared with the 12 months following ablation.

Results: Disease-specific and generic HRQOL was moderately to severely impaired at baseline and improved significantly at 6 and 12 months of follow-up (median improvement in AFEQT [Atrial Fibrillation Effect on QualiTy of Life] score 32.4 [interquartile range: 17.7 to 48.9]). When compared with the 12 months pre-ablation, the proportion and absolute number of cardioversions decreased significantly (41.1% vs. 10.1% of patients, 137 vs. 35 events; p < 0.0001). Similar significant reductions in emergency department visits (66.7% vs. 25.1% of patients, 224 vs. 87 events; p < 0.0001), and hospitalizations (25.5% vs. 14.5% of patients, 86 vs. 50 events; p < 0.001) were observed. There were no significant differences between randomized groups.

Conclusions: In this multicenter randomized trial, catheter ablation with advanced-generation technologies resulted in a significant improvement in HRQOL and a significant reduction in health care utilization in the year following AF ablation. (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation [CIRCA-DOSE]; NCT01913522).
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http://dx.doi.org/10.1016/j.jacep.2020.04.017DOI Listing
August 2020

Arterial Stiffness Association With Symptom Burden in Patients With Atrial Fibrillation: Direct Cause or Marker of Concomitant Risk Factors?

Can J Cardiol 2020 12 15;36(12):1843-1846. Epub 2020 Aug 15.

Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia; Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark. Electronic address:

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http://dx.doi.org/10.1016/j.cjca.2020.08.003DOI Listing
December 2020

Propensity-matched registry results: too good to be true?

Eur J Cardiothorac Surg 2021 01;59(1):281

McMaster University, Hamilton, ON, Canada.

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http://dx.doi.org/10.1093/ejcts/ezaa251DOI Listing
January 2021

Hemoptysis and Cryoballoon Ablation: Is it Crystal Clear?

JACC Clin Electrophysiol 2020 07;6(7):783-785

Heart Rhythm Services, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Center for Cardiovascular Innovation, Vancouver, British Columbia, Canada.

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http://dx.doi.org/10.1016/j.jacep.2020.05.033DOI Listing
July 2020

Repeat Atrial Fibrillation Ablation Procedures in the CIRCA-DOSE Study.

Circ Arrhythm Electrophysiol 2020 09 23;13(9):e008480. Epub 2020 Jul 23.

Department of Medicine, University of British Columbia, Vancouver, Canada (C.C.C., M.W.D., J.G.A.).

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http://dx.doi.org/10.1161/CIRCEP.120.008480DOI Listing
September 2020

Health-Related Quality of Life in Patients With Atrial Fibrillation Treated With Catheter Ablation or Antiarrhythmic Drug Therapy: A Systematic Review and Meta-analysis.

CJC Open 2020 Jul 2;2(4):286-295. Epub 2020 Apr 2.

School of Nursing, McMaster University, Hamilton, Ontario, Canada.

Background: Catheter ablation (CA) is performed in patients with atrial fibrillation (AF) to reduce symptoms and improve health-related quality of life (HRQL).

Methods: This systematic review and meta-analysis of randomized controlled trials (RCTs) evaluated CA of any energy modality compared with antiarrhythmic drugs (AADs) using inverse-variance random-effects models. We searched for RCTs reporting HRQL and AF-related symptoms at 3, 6, 12, 24, 48, and 60 months after treatment as well as the number of repeat ablations.

Results: Of 15,878 records, we included 13 RCTs of CA vs AADs for the analyses of HRQL, 7 RCTs for the analyses of AF-related symptoms, and 13 RCTs for the number of repeat ablations. For the HRQL analyses at 3 months, there were significant increases in both the Physical Component Summary score (3 months' standardized mean difference = 0.58 [0.39-0.78]; < 0.00001,  = 6%, 3 trials, n = 443) and the Mental Component Summary score (3 months' standardized mean difference = 0.57 [0.37-0.77]; < 0.00001,  = 0%, 3 trials, n = 443), favouring CA over AADs. These differences were sustained at 12 months but not >24 months after randomization. Similar results were seen for AF-related symptoms. The number of repeat ablations and success rates after procedure varied considerably across trials.

Conclusions: Evidence from few trials suggests that CA improves physical and mental health and AF-related symptoms in the short term, but these benefits decrease with time. More trials, reporting both HRQL and AF-related symptoms, at consistent time points are needed to assess the effectiveness of CA for the treatment of AF.
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http://dx.doi.org/10.1016/j.cjco.2020.03.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7365832PMC
July 2020

Establishing reference ranges for ambulatory electrocardiography parameters: meta-analysis.

Heart 2020 Nov 20;106(22):1732-1739. Epub 2020 Jul 20.

Heart Rhythm Services, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada

Objective: Despite the widespread and increasing use of ambulatory electrocardiography (ECG), there is no consensus on reference ranges for ambulatory electrocardiogram parameters to guide interpretation. We sought to determine population distribution-based reference ranges for parameters measured during ambulatory electrocardiogram in healthy adults, based on existing literature.

Methods: We searched multiple databases from 1950 to 2020. Articles reporting original data from ≥24-hour ambulatory electrocardiogram monitoring in healthy adults were included. Data extraction and synthesis were performed according to Meta-analysis of Observational Studies in Epidemiology guidelines. The prevalence/mean and SD for common parameters (sinus pauses, conduction abnormalities and ectopy) were extracted by age group (18-39, 40-59, 60-79 and 80+ years).

Results: We identified 33 studies involving 6466 patients. Sinus pauses of >3 s were rare (pooled prevalence <1%) across all ages. Supraventricular ectopy of >1000/24 hours increased with age, from 0% (95% CI 0% to 0%) in those aged 18-39 years to 6% (95% CI 0% to 17%) in those aged 60-79 years. Episodes of supraventricular tachycardia increased from 3% (95% CI 1% to 6%) in those aged 18-39 years to 28% (95% CI 9% to 52%) in those aged 60-79 years. Ventricular ectopy of >1000/24 hours also increased with age, from 1% (95% CI 0% to 2%) in those aged 18-39 years to 5% (95% CI 1% to 10%) in those aged 60-79 years. Episodes of non-sustained ventricular tachycardia ranged from 0% (95% CI 0% to 1%) in those aged 18-39 years to 2% (95% CI 0% to 5%) in those aged 60-79 years.

Conclusion: Despite the limitations of existing published data, this meta-analysis provides evidence-based reference ranges for ambulatory electrocardiogram parameters and highlights significant age-dependent differences that should be taken into account during interpretation.
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http://dx.doi.org/10.1136/heartjnl-2020-316925DOI Listing
November 2020

The Cryoballoon vs Irrigated Radiofrequency Catheter Ablation (CIRCA-DOSE) Study Results in Context.

Arrhythm Electrophysiol Rev 2020 Jun;9(1):34-39

Montreal Heart Institute, Department of Medicine, University of Montreal, Montreal, Canada.

The Cryoballoon vs Irrigated Radiofrequency Catheter Ablation: Double Short vs Standard Exposure Duration (CIRCA-DOSE) study was a multicentre, randomised, single-blinded trial that compared contact-force radiofrequency ablation and two different regimens of cryoballoon ablation. All patients received an implantable cardiac monitor for the purpose of continuous rhythm monitoring, with all arrhythmia events undergoing independent adjudication by a committee blinded to treatment allocation. The study demonstrated there were no significant differences between contact-force radiofrequency ablation and cryoballoon ablation with respect to recurrence of any atrial tachyarrhythmia, symptomatic atrial tachyarrhythmia, asymptomatic AF, symptomatic AF or AF burden. While the results of the CIRCA-DOSE study are reviewed here, this article focuses on considerations around the design of the study and places the observed outcomes in context.
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http://dx.doi.org/10.15420/aer.2019.13DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330729PMC
June 2020

Impact of Left Common Pulmonary Veins in the Contact-Force vs. Cryoballoon Atrial Fibrillation Ablation (CIRCA-DOSE) Study.

J Cardiovasc Electrophysiol 2020 Jul 6. Epub 2020 Jul 6.

Heart Rhythm Services, Department of Medicine, University of British Columbia, Canada.

Background: Concerns remain regarding the effectiveness of PVI using the fixed diameter non-compliant cryoballoon in the presence of a left common pulmonary vein (LCPV). We sought to evaluate the effectiveness of PVI performed by contact-force guided radiofrequency (CF-RF) versus second-generation cryoballoon-based ablation in patients with LCPV.

Methods And Results: We enrolled 346 patients with paroxysmal AF and randomized them to CF-RF or cryoballoon ablation. PV anatomy was not assessed prior to enrolment, and there were no exclusions based on PV anatomy. All patients received an implantable cardiac monitor. LCPV was observed in 13.6% of patients (47/346). Left atrial time and fluoroscopy time did not differ between those with and without LCPV (P=0.58 and P=0.06, respectively). Freedom from any atrial tachyarrhythmia at one year was observed in 46.8% with LCPV and 54.5% without LCPV (P=0.06). In those with LCPV the freedom from any atrial tachyarrhythmia did not differ between those randomized to CF-RF or cryoballoon ablation (HR for recurrence 1.19, 95% CI 0.53-2.65, P=0.69). In those with LCPV the AF burden was reduced to a similar extent with CF-RF and cryoballoon ablation (99.7% vs. 99.5%, respectively; P=0.97).

Conclusions: In this randomized clinical trial, the presence of a LCPV was associated with a trend towards higher rates of arrhythmia recurrence following PVI. No significant difference in arrhythmia recurrence was observed between patients with LCPV randomized to cryoballoon ablation or contact-force guided RF ablation, suggesting that either ablation modality is suitable in this population. (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation [CIRCA-DOSE], NCT01913522) This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1111/jce.14652DOI Listing
July 2020

Association of Atrial Fibrillation Episode Duration With Arrhythmia Recurrence Following Ablation: A Secondary Analysis of a Randomized Clinical Trial.

JAMA Netw Open 2020 07 1;3(7):e208748. Epub 2020 Jul 1.

Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Quebec, Canada.

Importance: Contemporary guidelines recommend that atrial fibrillation (AF) be classified based on episode duration, with these categories forming the basis of therapeutic recommendations. While pragmatic, these classifications are not based on pathophysiologic processes and may not reflect clinical outcomes.

Objective: To evaluate the association of baseline AF episode duration with post-AF ablation arrhythmia outcomes.

Design, Setting, And Participants: The current study is a secondary analysis of a prospective, parallel-group, multicenter, single-masked randomized clinical trial (the Cryoballoon vs Irrigated Radiofrequency Catheter Ablation: Double Short vs Standard Exposure Duration [CIRCA-DOSE] study), which took place at 8 Canadian centers. Between September 2014 and July 2017, 346 patients older than 18 years with symptomatic AF referred for first catheter ablation were enrolled. All patients received an implantable cardiac monitor at least 30 days before ablation. Data analysis was performed in September 2019.

Exposure: Before ablation, patients were classified based on their longest AF episode. Ablation consisted of circumferential pulmonary vein isolation using standard techniques.

Main Outcomes And Measures: Time to first recurrence of symptomatic or asymptomatic atrial tachyarrhythmia (AF, atrial flutter, or atrial tachycardia) following ablation and AF burden (percentage of time in AF) on preablation and postablation continuous rhythm monitoring.

Results: The study included 346 patients (mean [SD] age, 59 [10] years; 231 [67.7%] men). Overall, 263 patients (76.0%) had AF episode duration of less than 24 hours; 25 (7.2%), 24 to 48 hours; 40 (11.7%), 2 to 7 days; and 18 (5.2%), more than 7 days. Documented recurrence of any atrial tachyarrhythmia following ablation was significantly lower in patients with baseline AF episode duration of less than 24 continuous hours compared with those with longer AF episodes (24 hours vs 24-48 hours: hazard ratio [HR], 0.41; 95% CI, 0.21-0.80; P = .009; 24 hours vs 2-7 days: HR, 0.25; 95% CI, 0.14-0.45; P < .001; 24 hours vs >7 days: HR, 0.23; 95% CI, 0.09-0.55; P < .001). Patients with preablation AF episodes limited to less than 24 continuous hours had a significantly lower median (interquartile range) postablation AF burden (0% [0%-0.1%]) compared with those with AF preablation episodes lasting 2-7 days (0.1% [0%-1.0%]; P = .003) and those with AF preablation episodes lasting more than 7 days (1.0% [0%-5.4%]; P = .008). There was no significant difference in arrhythmia recurrence or AF burden between the 3 groups with a baseline AF episode duration of longer than 24 hours.

Conclusions And Relevance: In this study, patients with AF episodes limited to less than 24 continuous hours had a significantly lower incidence of arrhythmia recurrence following AF ablation. This suggests that current guidelines for classification of AF may not reflect clinical outcomes.

Trial Registration: ClinicalTrials.gov Identifier: NCT01913522.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.8748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7333024PMC
July 2020

In-hospital and long-term outcomes among patients with spontaneous coronary artery dissection presenting with ventricular tachycardia/fibrillation.

Heart Rhythm 2020 11 24;17(11):1864-1869. Epub 2020 Jun 24.

Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Background: Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in young to middle-age women. Ventricular tachycardia/ventricular fibrillation (VT/VF) may complicate acute SCAD presentations, and the long-term outcomes are unknown.

Objective: The purpose of this study was to report the outcomes of SCAD patients presenting with VT/VF.

Methods: We analyzed our prospective Canadian SCAD registries for patients presenting with VT/VF during index hospitalization. Long-term outcomes including VT/VF and cardiac arrest were collected. Univariate and multivariable analyses were performed to identify predictors of VT/VF at follow-up.

Results: Among 1056 consecutive SCAD patients, 84 (8.0%) presented with VT/VF, and 8 underwent implantable cardioverter-defibrillator (ICD) insertion. Patients with VT/VF during index hospitalization were younger (49.3 vs 52.0 years; P = .019) and were more likely to have ST-elevation MI, lower left ventricular ejection fraction (LVEF), and left main dissection (all P <.001). Initial VT/VF was associated with in-hospital events, including recurrent MI, unplanned revascularization, heart failure, ICD insertion, and in-hospital death (all P <.05). At mean follow-up of 4.8 ± 3.3 years, 8 patients suffered VT/VF (time to event 5.2 ± 6.2 years); 5 of 8 patients had VT/VF on initial SCAD presentation, and 1 of 8 had undergone ICD insertion. Predictors of VT/VF during follow-up included LVEF <50%, LVEF <35%, peripartum SCAD, unplanned revascularization, repeat MI, heart failure, and initial VT/VF. Multivariable analysis showed initial VT/VF (odds ratio [OR] 9.5; 95% confidence interval [CI] 2.0-44; P = .004) and LVEF <50% (OR 12.9; 95% CI 1.5-111; P = .019) were independent predictors of VT/VF at follow-up.

Conclusion: SCAD patients presenting with VT/VF were at greater risk for in-hospital events and recurrent VF/VT at follow-up. Both VT/VF and LVEF <50% were independent predictors of subsequent VT/VF.
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http://dx.doi.org/10.1016/j.hrthm.2020.06.019DOI Listing
November 2020

Considerations in Adult Congenital Heart Disease and Stroke: A Case Report.

Stroke 2020 08 24;51(8):e148-e150. Epub 2020 Jun 24.

University of British Columbia Faculty of Medicine, Vancouver, Canada (N.L.). Vancouver Stroke Program, Division of Neurology, University of British Columbia, British Columbia, Canada (J.M.C.S., T.S.F.). Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (J.G.A.). Department of Medicine, Université de Montréal, Montreal, Quebec, Canada (J.G.A.). Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, British Columbia, Canada (A.M.F.). Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada (A.M.F.).

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http://dx.doi.org/10.1161/STROKEAHA.119.028605DOI Listing
August 2020

Efficacy and Safety of Same-Day Discharge for Atrial Fibrillation Ablation.

JACC Clin Electrophysiol 2020 06 29;6(6):609-619. Epub 2020 Apr 29.

Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.

Objectives: The purpose of this study was to evaluate the efficacy, health care utilization, and safety of a same-day discharge protocol.

Background: Catheter ablation of atrial fibrillation (AF) is the most common ablation performed. Increasing volumes of AF ablation are placing demands on hospital resources. In response, our institutions developed a same-day discharge protocol for AF ablation.

Methods: This was a multicenter cohort study of all patients undergoing AF ablation from 2010 to 2014 at 2 major centers. The primary efficacy outcome was the proportion of successful same-day discharges. The primary health care utilization outcome was 30-day hospital readmission for any reason. The primary safety outcome was a composite of 30-day death, stroke/transient ischemic attack or embolism, or bleeding requiring hospitalization.

Results: A total of 3,054 patients underwent AF ablation from 2010 to 2014 and met inclusion criteria. Same-day discharge was achieved in 79.2% (2,418 of 3,054). Hospital readmission at 30 days was 7.7% for the same-day discharge group, 10.2% for those who remained in the hospital overnight without complications (p = 0.055 for comparison with same-day discharge), and 19.5% (p < 0.001) for those who remained in the hospital with procedural complications (7.7%). Complication rates from discharge to 30 days (excluding immediate procedural complications) were 0.37% for the same-day discharge group, 0.36% (p = 0.999) for those kept overnight without complications, and 2.5% (p = 0.044) for those with initial procedural complications.

Conclusions: Same-day discharge after AF ablation is feasible in the majority of patients with use of a standardized protocol. This approach was not associated with higher hospital readmission or complication rates after discharge.
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http://dx.doi.org/10.1016/j.jacep.2020.02.009DOI Listing
June 2020