Daily Cardiology Research Analysis
A network meta-analysis of 46 RCTs found that thoracoscopic surgical and hybrid ablation strategies yield greater freedom from atrial fibrillation than catheter-based approaches but with higher procedural complications. A large post-myectomy cohort showed current guideline ICD risk frameworks underperform, while LV wall thickness and late gadolinium enhancement strongly predict sudden death risk. A UK Biobank analysis identified sinus node dysfunction as an independent risk marker for ischemic s
Summary
A network meta-analysis of 46 RCTs found that thoracoscopic surgical and hybrid ablation strategies yield greater freedom from atrial fibrillation than catheter-based approaches but with higher procedural complications. A large post-myectomy cohort showed current guideline ICD risk frameworks underperform, while LV wall thickness and late gadolinium enhancement strongly predict sudden death risk. A UK Biobank analysis identified sinus node dysfunction as an independent risk marker for ischemic stroke even without atrial fibrillation.
Research Themes
- Comparative effectiveness of atrial fibrillation ablation strategies
- Post-myectomy sudden cardiac death risk stratification in hypertrophic cardiomyopathy
- Stroke risk associated with sinus node dysfunction independent of atrial fibrillation
Selected Articles
1. Effectiveness and safety of different types of ablation modalities in patients with atrial fibrillation: a bayesian network meta-analysis from randomized controlled trials.
Across 46 RCTs (N=6,332), VATS surgical and hybrid ablation achieved higher freedom from AF than catheter-only approaches (VATS OR 1.54; SUCRA 89.6; hybrid SUCRA 85.7). AF type and duration modified efficacy, while surgical/hybrid strategies carried higher rates of mortality, pericardial effusion, and phrenic nerve injury.
Impact: This comprehensive, PROSPERO-registered network meta-analysis synthesizes RCTs to inform comparative effectiveness of AF ablation strategies, highlighting trade-offs between efficacy and complications.
Clinical Implications: Consider VATS or hybrid ablation for selected patients with persistent/long-standing AF, balancing improved efficacy against higher procedural risks; tailor choices by AF type and duration with shared decision-making and specialized center expertise.
Key Findings
- VATS surgical ablation ranked highest for freedom from AF (OR 1.54; 95% CrI 1.03–2.38; SUCRA 89.61).
- Hybrid epicardial–endocardial ablation showed efficacy comparable to VATS (SUCRA 85.7).
- AF type (β −0.415) and AF duration (β 0.602) significantly influenced outcomes in meta-regression.
- Surgical/hybrid approaches had higher risks of mortality (5.07%), pericardial effusion (4.35%), and phrenic nerve injury (4.35%).
Methodological Strengths
- PROSPERO-registered, PRISMA-compliant Bayesian network meta-analysis of 46 RCTs
- Sensitivity, subgroup, and meta-regression analyses with SUCRA ranking and GLMM safety estimates
Limitations
- Heterogeneity across trials and reliance on indirect comparisons
- Safety outcomes derived from meta-proportions with potential reporting bias
Future Directions: Head-to-head RCTs comparing surgical/hybrid versus catheter ablation with standardized endpoints; risk tools integrating AF type/duration and patient profiles; cost-effectiveness and long-term safety studies.
2. Prediction of sudden death in obstructive hypertrophic cardiomyopathy after septal myectomy: Targeting the candidate.
In 1,915 post-myectomy HCM patients, current AHA/ESC ICD stratification did not predict SCD, whereas LV wall thickness and LGE were significant predictors. Patients with LVWT ≥30 mm and LGE ≥15% had markedly elevated SCD risk (sHR 5.60).
Impact: Challenges guideline-based ICD risk assessment after myectomy and identifies robust imaging thresholds (LVWT and LGE) to refine candidate selection.
Clinical Implications: Post-myectomy SCD risk assessment should incorporate CMR LGE burden and LV wall thickness; guideline algorithms may need revision. Consider ICD in patients with LVWT ≥30 mm and LGE ≥15% after multidisciplinary review.
Key Findings
- Guideline-based AHA/ESC ICD recommendations did not significantly discriminate SCD events post-myectomy.
- LV wall thickness and LGE independently predicted SCD (P=0.028 and P=0.015).
- LVWT ≥30 mm plus LGE ≥15% identified a high-risk subgroup (sHR 5.60; 95% CI 1.90–16.5).
- Cardiac index showed a nonlinear association with SCD risk.
Methodological Strengths
- Large single-procedure cohort (n=1,915) with competing-risk modeling
- Use of CMR LGE quantification and detailed imaging predictors
Limitations
- Retrospective design with potential residual confounding and low absolute event count
- Generalizability may be limited to centers with extensive myectomy and CMR expertise
Future Directions: Prospective, multi-center validation of LGE/LVWT thresholds and incorporation into post-myectomy SCD risk scores; assessment of ICD benefit in imaging-defined high-risk subgroups.
3. Risk of ischemic stroke in sinus node dysfunction with and without atrial fibrillation: Evidence for the presence of a left atrial myopathy in patients with isolated sinus node dysfunction-an analysis of the UK Biobank.
In >451,000 UK Biobank participants with 13.2 years of follow-up, isolated sinus node dysfunction doubled ischemic stroke risk versus controls (sHR 2.28), even without AF. Stroke risk in SND+AF was similar to AF alone, supporting SND as a marker of atrial myopathy.
Impact: This large, prospective population analysis identifies SND as an independent stroke risk marker, reframing stroke prevention strategies beyond AF alone.
Clinical Implications: Patients with SND may warrant closer cerebrovascular risk assessment and management even without AF. Future strategies could consider atrial myopathy markers, not only arrhythmia presence, for anticoagulation decisions.
Key Findings
- Isolated SND was associated with higher ischemic stroke risk vs controls (sHR 2.28; 95% CI 1.57–3.31).
- Annual IS incidence: 0.37% (isolated SND), 0.60% (SND+AF), 0.59% (AF), 0.10% (controls).
- Stroke risk in SND+AF was similar to isolated AF (sHR 1.07; P=0.58), supporting atrial myopathy involvement.
Methodological Strengths
- Very large prospective cohort with long follow-up and comprehensive EHR linkage
- Competing-risk regression modeling adjusting for death
Limitations
- Observational design with potential residual confounding and coding misclassification
- Lack of granular rhythm monitoring may under-detect subclinical AF
Future Directions: Prospective studies to test anticoagulation strategies guided by atrial myopathy markers; integration of imaging/biomarkers to refine stroke prevention in SND without AF.