In this ppt i am going to discuss regarding two important paper published in Journal of American college of cardiology in May, June 2017.

1. Journal Scan
Presenter
Praveen gupta
Moderator
Dr Raja selvaraj
Department of cardiology
JIPMER
Pondicherry
India
03.07.2017
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3. Introduction
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 Catheter ablation standard therapy for AF
 Recurrence after pulmonary vein isolation (PVI) is electrical reconnection between PV) and the left atrium
(LA).
 Presence of non-PV foci (NPVF) is related to AF recurrence after multiple PVI procedures, as well as to
very late AF recurrence
 Impact of NPVF on AF recurrence has not evaluated
 Present study used examine NPVF prevalence in the first and second PVI sessions and evaluate the impact
of NPVF on AF recurrence after catheter ablation for LA-PV reconnection

4. Methods
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 Retrospectively analyzed
 284 patients with drug-refractory paroxysmal atrial fibrillation (PAF) (232) or persistent
atrial fibrillation (PeAF) (52), who underwent PVI between February 2010 and February
2014 at the Tokyo Metropolitan Hiroo Hospital
 Patients were excluded,
 PeAF lasting >1 year (61)
 Short interval between the first and second procedures ( 2)
 Use of amiodarone during the procedure (3 patients)
 Followup <1 year

5. Methods
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 A total of 216 patients (172 with PAF and 44 with PeAF lasting <1 year) were included
(76%)
 All patients underwent a second electrophysiological study at the 6-month follow-up after the
first procedure, regardless of AF recurrence
 Performed PVI and catheter ablation for NPVF in the first and second sessions.
 NPVF detected for the first time in the second session were defined as newly developed
NPVF (new-NPVF)
 Each patient to either the new-NPVF(+) or new-NPVF(-) group, depending on whether
they developed NPVF between the first and second session

6. Methods
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7. Result
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8. 8
Result

9. 9
Result

10. 10
Result

11. Discussion
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 Prevalence of NPVF higher in the second session than in the first
 New-NPVF in the second session correlated to AF recurrence after repeated catheter ablation
 AF history and AF recurrence after the first session were predictors for patients likely to
develop new-NPVF
 Proportion with NPVF was 9.6% in the first session
 Proportion with NPVF in second session was lower than in previous reports
 Among the patients with AF recurrence after the first session, 19 (33.9%) had new-NPVF,
indicating increased prevalence of NPVF as a trigger for recurrent AF after PVI
 NPVF originating from the interatrial septum in 22%

12. Discussion
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 OUTCOME AFTER THE SECOND SESSION
 NPVF important risk factor for AF recurrence after second session in patients with PAF
 Patients without AF recurrence 6 months after the first session had new-NPVF and AF recurrences after
the second procedure
 These patients are prone to develop late recurrence after PVI
 Ablation for new-NPVF highly recommended to avoid future recurrences
 NPVF in the LA area had a higher recurrence than with NPVF in the SVC or crista terminalis
 Patients who show new-NPVF, long follow-up with additional medication needed

13. Discussion
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 PREDICTORS FOR NEW-NPVF.
 AF history
 NPVF in the first session
 Longer AF duration
 AF type was not related to new-NPVF
 Sex and LA volume were not predictors for new-NPVF

14. Discussion
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 AF TRIGGERS AND ORIGIN
 Patients without AF recurrence after the first session had high PV reconnection rate (68.2%,
107 of 157)
 New-NPVF independent predictor for AF recurrence after the second session, even when
these foci were ablated. .

15. Study limitations
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 Single-center
 Retrospective study.
 Follow-up period was short (230 days)
 Proportion of patientswith NPVF might be underestimated; indeed, NPVF
 Occurrence was lower than that reported in previous studies.
 Some patients had AF recurrence due to LA-PV reconnection even after the second session
 We did not target NPVF that did not induce AF, which influenced our results
 Electrocardiography and 24-h Holter electrocardiographic monitoring every 3 to 6 months after the
procedure is insufficient to detect AF episodes in patients with asymptomatic AFrecurrence

16. Conclusions
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 Higher number of NPVF were detected in the second session of PVI
 Distribution of NPVF location and number were also different than during the first session
 Occurrence of NPVF developed after the first PVI session was correlated with AF recurrence
after catheter ablation of LA-PV reconnection
 Long AF history and AF recurrence after the first session need additional ablation for NPVF
 AF triggers, with long-term follow-up
 NPVF detection and ablation may represent important therapeutic options to prevent AF
recurrence, especially in patients who require repeated procedures.

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18. 18

19. Introduction
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 HRV capture intervals between consecutive normal heart beats
 Reflect cardiac autonomic function
 Abnormal HRV independent predictor of sudden cardiac death in CHF
 PVCs from 24-h Holter associated with development of heart failure
 We hypothesized that abnormal HRV identify participants who are at an increased risk for the
development of CHF

20. Method
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 Noninstitutionalized individuals 65 years of age or older
 5,201 participants, recruited from 1989 to 1990.
 687 African-American individuals were recruited from 1992 to 1993
 Physical examinations, laboratory tests, and questionnaires obtained
 Holter recording done at year 2 of the CHS, whereas the African-American had baseline
assessments at year 5, had Holter recordings performed in year 7

21. Exclusion criteria
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 Participants with unusable Holter data (i.e., paced rhythms, atrial fibrillation, wandering
atrial pacemaker, or >20% ectopic beats)
 Heart failure at time of Holter monitoring
 Those with unknown baseline heart failure status
 Patient with missing components of Health ABC score
 Participants excluded due to incomplete follow-up data.

22. Outcomes
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 Primary outcome-Incident CHF
 Heart failure, MI, and stroke tabulated through regular surveys, clinic visits, and calls
 Participants were able to report any changes in their medical care
 Incident events explored through medical records including discharge summaries, hospital
face sheets, or using International Classification of Diseases-Ninth

23. Ambulatory ECG monitoring and assessment of HRV
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 Holter tapes were recorded
 Holter analyses were reviewed by an investigator
 Only beats with uniformly detected onsets were labeled as normal
 The longest and shortest true N–N intervals were identified
 Time domain, frequency domain, and nonlinear HRV measures were determined
 Heart rate turbulence (HRT), a relatively novel measure of heart rate responses to isolated
PVCs, was also calculated
 HRT is generally reported as the categorical variables turbulence onset (TO) and turbulence
slope (TS)
 TS 3.0 ms/RR was categorized as normal, whereas TO 0% considered normal

24. Results
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 260 participants (19%) developed CHF during follow-up (median 10.5 years)
 CHF patient were more likely male, older, and higher body mass index.
 CHF patient have higher baseline heart rate and systolic blood pressure, as well as higher
baseline NT-proBNP, creatinine, and fasting glucose levels
 More likely to have left ventricular hypertrophy and CAD
 Participants who developed CHF had decreased 24-h HRV and circadian HRV
 Significant differences seen in very low frequency (VLF) power

25. Results
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 Participants who developed CHF, nonlinear HRV measures that capture the organization of
the heart rate time series were significantly more abnormal, reflecting greater disorganization
in heart rate control
 Abnormal HRT slope and onset more prevalent in those developed CHF
 Ventricular and atrial ectopy counts significantly higher in the CHF group
 24-h mean heart rate not different between with and without incident CHF

26. Subgroup analysis
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 A comparison of Holter-based parameters in the subset of participants with a baseline NT-
proBNP 190 pg/ml (1,000), who did (142, 14.2%) and did not (858, 85.8%) develop CHF can
be seen
 Participants who developed CHF in this subcohort had significantly higher Health ABC
scores

27. Discussion
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 Increased ventricular ectopy counts and abnormal HRV measures from 24-h Holter
recordings, including decreased DFA1, decreased CV%, increased ln VLF, and abnormal
HRT onset, added to the predictive power of the Health ABC score to identify asymptomatic
older adults who are at increased risk of developing CHF
 The model C-statistic increased from 0.73 to 0.77 when HRV was included.
 Low-risk subcohort, as defined by NT-proBNP #190 pg/ml, the Health ABC components
significantly associated with CHF were unchanged, and decreased DFA1 remained
independently associated with incident CHF

28. Result
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 HRV parameters were associated with incident CHF independent of the Health ABC score components
 Older adults who have cardiac autonomic dysfunction, as manifested by abnormal HRV, may be
predisposed to the development of CHF
 DFA1, first described by Peng et al, measures the randomness of the N-N intervals (i.e., the intervals
between normal heart beats in a time series
 Lower value of DFA1 reflect a more disorganized, less predictable sinus rhythm
 Lower DFA1 was associated with increased mortality in patients with reduced ejection fraction after MI

29. Result
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 Decreased DFA1 with increased heart failure hospitalizations
 Decreased DFA1 a strong risk factor for cardiovascular death
 Relationship between DFA1 and incident CHF in asymptomatic older adults
 Study confirmed that an increased number of PVCs was associated with an increased risk of
CHF, independent of the Health ABC score components,

30. Study limitations
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 HRV can only be measured in normal sinus rhythm, which exclude those with atrial
fibrillation, wandering atrial pacemaker, excessive ectopy, or an underlying paced rhythm,
excluding individuals who are at the greatest risk of developing CHF
 Health ABC score components were obtained 2 years before the Holter recordings in the
African-American cohort, these participants may have had a different Health ABC score at
the time of their 24-h Holter measurements

31. Study limitations
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 we did not correct for multiple comparisons, thereby increasing the risk of type I error.
 Full clinical application of these findings would require that 24-h Holter recordings be
analyzed to research standards

32. Conclusions
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 Abnormal HRV significantly and independently associated with incident CHF
 When combined with increased PVCs, improved the predictive power of the Health ABC
score
 Among low-risk older adults with NTproBNP 190 pg/ml, HRV added to the clinical risk
model.
 Identification of asymptomatic older adults with abnormal HRV could potentially help direct
targeted strategies for the primary prevention of heart failure

33. Take home message
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 NPVF detection and ablation may represent important therapeutic options to prevent AF
recurrence, especially in patients who require repeated procedures
 Abnormal HRV significantly and independently associated with incident CHF

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Thank You