In this issue: > LAA occlusion for patients with AF and intracranial bleeding

> Effective AF suppression by ivabradine > NOACs for stroke prevention in new-onset AF

> AF predictors in hypertrophic cardiomyopathy

> Morphology and flow velocity of LAA in AF ±TIA/cardioembolic stroke

> Increased mortality in low socioeconomic status patients with AF

> Stroke/major bleeding and creatinine clearance in AF

> AF inducibility during cavotricuspid isthmus-dependent atrial flutter

> Duty-cycled phased RF ablation for paroxysmal AF

> FIRM for AF > Novel mapping technique for distinguishing focal and re-entrant activation during AF

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Before prescribing, please review PBS and full Product Information in the primary advertisement in this publication. Please click here for access to the full Product Information.References: 1. PRADAXA Product Information. 2. PRAXBIND Product Information. Further information is available on request from Boehringer Ingelheim. Pradaxa® and Praxbind® are registered trademarks of Boehringer Ingelheim Pty Limited, ABN 52 000 452 308, 78 Waterloo Road, North Ryde NSW 2113. AUS/PRA-171033 S&H BOIPX0093-AFRR-BAN. January 2017.

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Issue 37 - 2017Making Education Easy

AF = atrial fibrillation; FIRM = focal impulse and rotor modulation;LA(A) = left atrial (appendage); NOAC = nonvitamin K oral anticoagulant;PV(I) = pulmonary vein (isolation); RF = radiofrequency;TIA = transient ischaemic attack.

Abbreviations used in this issue:

Welcome to issue 37 of Atrial Fibrillation Research Review.The research selected for this issue begins with an analysis of registry data reporting that LAA occlusion appears to be safe and significantly reduces stroke/TIA with a low frequency of major bleeding in patients with nonvalvular AF and a history of intracranial bleeding. Other registry data analyses included in this issue report on factors associated with selecting NOACs over warfarin for stroke prevention in patients with AF, and on increased adverse clinical events, including stroke/systemic embolism, in patients with AF who have reduced creatinine clearance. This issue concludes with interesting research demonstrating that a new mapping technology (Ripple Map) enabled quick identification of AF wavefront activation patterns in patients undergoing ablation for persistent AF.

I hope you find these and the other included research papers interesting. I appreciate receiving your comments and suggestions.

Kind Regards,

Dr Andrei Catanchinandrei.catanchin@researchreview.com.au

Patients with intracranial bleeding and atrial fibrillation treated with left atrial appendage occlusionAuthors: Tzikas A et al.Summary: The procedural safety and long-term outcomes following LAA occlusion therapy due to previous intracranial bleeding were explored using data from 1047 consecutive patients with nonvalvular AF entered into the Amplatzer Cardiac Plug registry, 198 of whom had previously experienced intracranial bleeding. Patients with versus without prior intracranial bleeding had similar CHA2DS2VASc scores (4.5 vs. 4.4), but those who had a history of intracranial bleeding had a higher HAS-BLED score (3.5 vs. 3.1 [p

Before prescribing please review PBS and Product Information in the primary advertisement in this publication. Please click here for access to the full Product Information

References: 1. PRADAXA Product Information. 2. PRAXBIND Product Information. 3. Therapeutic Goods Administration. Reasons for scheduling delegate’s final decisions - NCEs (Medicines) - April 2016. 1.6 Idarucizumab. Available at: https://www.tga.gov.au/book-page/16-idarucizumab. Accessed 3 May 2016. Further information is available on request from Boehringer Ingelheim. Pradaxa® and Praxbind® are registered trademarks of Boehringer Ingelheim Pty Limited, ABN 52 000 452 308, 78 Waterloo Road, North Ryde NSW 2113. AUS/PRA-171033 S&H BOIPX0093-AFRR-HP. January 2017.

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BOIPX0093_AFRR_HP_[f].indd 1 1/27/17 10:42 AMwww.researchreview.com.au a RESEARCH REVIEW publication

2

Atrial Fibrillation Research ReviewTM

Factors associated with non–vitamin K antagonist oral anticoagulants for stroke prevention in patients with new-onset atrial fibrillationAuthors: Steinberg BA et al., on behalf of the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) Investigators and PatientsSummary: These authors analysed ORBIT-AF II trial data for 4670 participants with recently diagnosed AF to determine factors associated with NOAC versus warfarin selection. Warfarin was started at baseline in 1169 participants, with the others started on an NOAC, including dabigatran (n=259), rivaroxaban (n=1858) and apixaban (n=1384). Compared with warfarin recipients, NOAC recipients were of slightly younger median age (71 vs. 72 years [p

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Atrial Fibrillation Research ReviewTM

Comparison of morphologic features and flow velocity of the left atrial appendage among patients with atrial fibrillation alone, transient ischemic attack, and cardioembolic strokeAuthors: Lee Y et al.Summary: These researchers investigated differences in morphological and functional features of LAAs for patients with AF alone, and those who also had cardioembolic TIA or cardioembolic stroke. Their investigations found that the frequencies of the ‘cauliflower’ and ‘chicken wing’ LAA morphologies increased and decreased, respectively, according to the following group order: AF with no cerebrovascular accident, cardioembolic TIA and cardioembolic stroke. The cardioembolic TIA and cardioembolic stroke groups had greater LAA orifice diameters than the AF with no cerebrovascular accident group. The cardioembolic stroke group had greater LAA flow velocity than the other two groups. Multiple multinominal regression analyses revealed that both cardioembolic TIA and cardioembolic stroke were associated with cauliflower morphology; however, no associations with LAA morphology were evident after adjusting for orifice diameter and flow velocity. A receiver operating characteristic curve analysis showed that LAA orifice diameter and flow velocity were accurate predictors of cardioembolic TIA and cardioembolic stroke (respective c-statistics 0.839 and 0.896).

Comment: This study expands on the current knowledge of LAA anatomy and this now accepted nomenclature, also confirming previous observations linking poor LAA function (emptying velocity) with increased risk of stroke.

Reference: Am J Cardiol 2017;119(10):1596–604Abstract

Socioeconomic status as a predictor of mortality in patients admitted with atrial fibrillationAuthors: Kargoli F et al.Summary: The impact of socioeconomic status on all-cause mortality was retrospectively assessed in adults hospitalised with a primary diagnosis of AF stratified into socioeconomic status quartiles, with 1132, 1119, 1126 and 1126 patients in quartiles 1–4, respectively. Mean follow-up was 4.5 years. A multivariable analysis revealed that compared with patients from the highest socioeconomic status quartile, those from the lowest quartile had a significantly higher likelihood of mortality (odds ratio 1.3 [CI 1.1–1.5]).

Comment: As with many other medical conditions, low socioeconomic status predicts mortality in AF patients even after adjustment for common comorbidities.

Reference: Am J Cardiol 2017;119(9):1378–81Abstract

Relation of stroke and major bleeding to creatinine clearance in patients with atrial fibrillation (from the Fushimi AF Registry)Authors: Abe M et al.Summary: Clinical characteristics and adverse events were reported for 3080 Japanese registry patients with AF stratified as creatinine clearance

THE REASSURANCE OF REVERSALTHE CONFIDENCE OF EVIDENCE

PBS Information: PRADAXA: Authority required (STREAMLINED) for the prevention of stroke or systemic embolism in patients with non-valvular atrial fibrillation and one or more risk factors for developing stroke or systemic embolism. Authority required

(STREAMLINED) for prevention of venous thromboembolism in a patient undergoing total hip replacement or total knee replacement. This product is not listed on the PBS for treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE), or for the prevention of recurrent DVT and PE in adults. Refer to PBS Schedule for full authority information. PRAXBIND: This product is not listed on the PBS.

STREAMLINED AUTHORITY CODE 4269 for stroke prevention in non-valvular atrial fibrillation

Before prescribing please review the Product Information. Please click here for access to the full Product InformationFurther information is available on request from Boehringer Ingelheim. Pradaxa® and Praxbind® are registered trademarks of Boehringer Ingelheim Pty Limited, ABN 52 000 452 308, 78 Waterloo Road, North Ryde NSW 2113. AUS/PRA-171033 S&H BOIPX0093-AFRR-HP-P. January 2017.

BOIPX0093_AFRR_HP_Primary_[f].indd 1 1/27/17 10:42 AM

Novel mapping technique for localization of focal and reentrant activation during atrial fibrillationAuthors: Takahashi Y et al.

Summary: A novel combination of a new mapping technology (Ripple Map; a new feature in the CARTO®3) and high-density mapping to distinguish focal and re-entrant activation during AF was investigated in 45 patients undergoing ablation for persistent AF. Patients in whom AF persisted following PVI underwent LA mapping using a high-density mapping catheter on 569 sites for later analysis, after which ablation was continued using a conventional stepwise approach. Postprocedure electrograms from the high-density mapping catheter were analysed with Ripple Map to determine activation type for ≥3 consecutive AF cycles. There was good agreement of AF wavefront propagation between Ripple Map and analyses of manual annotations of bipolar electrograms. The wavefront activation pattern obtained by Ripple Map (which was able to include both local and far-field activity) allowed identification of focal activation in 11% of sites examined and one re-entrant activation site. Compared with atrial regions without focal activation on Ripple Map, RF delivery in regions with focal activation sites was associated with a greater AF termination rate (22% vs. 7% [p=0.015]).

Comment: The optimal ablation strategy in persistent AF remains unknown – the current standard is PVI using circumferential antral rings/lines. The benefits of additional lesion sets remain to be conclusively demonstrated.

Reference: J Cardiovasc Electrophysiol 2017;28(4):375–82Abstract

Focal impulse and rotor modulation for the treatment of atrial fibrillation: locations and 1 year outcomes of human rotors identified using a 64-electrode basket catheterAuthors: Tilz RR et al.Summary: These authors reported on 25 patients with AF who underwent FIRM (focal impulse and rotor modulation) mapping and ablation; ten patients had paroxysmal AF. The procedure involved use of a basket catheter for rotor identification within the right atrium then the left atrium, with RF energy applied at and around each rotor core for 300 seconds. When repeated rotor-mapping and ablation had eliminated all rotors, circumferential PVI was performed. Three rotors were identified per patient, mostly in the LA. Twelve patients had either AF termination or conversion to another rhythm, or cycle length prolongation of ≥10% after rotor ablation. Freedom from atrial tachyarrhythmia, following a single procedure, was reported for 52% of the patients after follow-up of 13 months.

Comment: FIRM ablation remains a somewhat controversial (and expensive) software-specific technique. Currently its place in routine ablation procedures remains to be determined.

Reference: J Cardiovasc Electrophysiol 2017;28(4):367–74Abstract

© 2017 RESEARCH REVIEW

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