Daily Cardiology Research Analysis

AIMS: A personalized pulmonary vein isolation (PVI) approach aimed at ablation index (AI) titration according to multidetector computed tomography-derived left atrial wall thickness (LAWT) maps reported high effectiveness and efficiency outcomes for persistent atrial fibrillation (PeAF) ablation. To date, no randomized trials have compared this approach with the standard CLOSE protocol. This non-inferiority randomized controlled trial sought to compare a LAWT-guided PVI with CLOSE protocol-based for PeAF (NCT05396534). METHODS AND RESULTS: Consecutive patients referred for first-time PeAF ablation were randomized on a 1:1 basis. In the by-LAWT arm, the AI was titrated according to local LAWT, and the ablation line was personalized to avoid the thickest regions at the pulmonary vein antrum. In the CLOSE arm, LAWT information was not available to the operator; the ablation was performed according to the CLOSE study settings: AI is ≥400 at the posterior wall and ≥550 at the anterior wall. Primary endpoint was freedom from atrial arrhythmias recurrence. Secondary endpoints were the major complication rate, procedure time, radiofrequency time, and first-pass PVI rate. One hundred fifty-six patients were included. At 12 month follow-up, no significant difference occurred in atrial arrhythmia-free survival between groups (P = 0.50). In the by-LAWT group, a significant reduction in procedure time (60.5 vs. 80.0 min; P < 0.01) and RF time (14.4 vs. 28.6 min; P < 0.01) was observed. No difference was observed regarding first-pass PVI (P = 0.72) and the major complication rate (P = 0.99). CONCLUSIONS: The PeAF-by-LAWT trial is the first prospective randomized study to demonstrate that a personalized LAWT-guided PVI for PeAF ablation is non-inferior to the standard CLOSE protocol in terms of arrhythmia-free survival while significantly improving procedural efficiency. The study was not powered to detect differences in safety outcomes.

AIMS: Coronary atherosclerosis tends to be non-calcified at early stages, questioning the implications of a coronary artery calcification score of zero (CAC = 0) at younger ages. This study investigates whether elevated low-density lipoprotein cholesterol (LDL-C) is associated with the presence of non-calcified plaques and future cardiovascular events in individuals with CAC = 0 across different ages. METHODS AND RESULTS: This cohort study from the Western Denmark Heart Registry included symptomatic individuals undergoing coronary computed tomography angiography (CCTA) from 2008-2021, with a 7.1-year median follow-up time. Outcomes included adjusted odds ratios (aOR) for non-calcified plaque on CCTA and adjusted hazard ratios (aHR) for coronary heart disease (CHD).The study included 23 777 individuals with CAC = 0. Median age was 54 (Q1-Q3 47-61) years, and 61% were women. The prevalence of non-calcified plaques was 11%. Per 1 mmol/L higher LDL-C, the overall aOR for non-calcified plaques was 1.21 [95% confidence interval (CI) 1.16-1.27]; corresponding values were 1.39 (1.23-1.56) at age ≤45, 1.22 (1.14-1.31) at age 46-60, and 1.11 (1.02-1.21) at age >60. During follow-up, 299 (1%) had a CHD event. Per 1 mmol/L higher LDL-C, the overall aHR was 1.28 (1.13-1.46) for CHD; corresponding values were 1.37 (1.04-1.82) at age ≤45, 1.24 (1.04-1.49) at age 46-60, and 1.26 (1.00-1.60) at age >60. CONCLUSION: In symptomatic individuals with CAC = 0, elevated LDL-C is associated with higher risk of non-calcified plaque and with higher relative risk of future CHD events, most pronounced at age ≤45 years. This indicates that LDL-C control over a long-time horizon remains important in younger individuals despite CAC = 0.

AIMS: Cardiac magnetic resonance-derived myocardial strain metrics are emerging as powerful early imaging biomarkers for the detection of cardiac dysfunction. This study utilized the UK Biobank to evaluate: (i) best practice for measurement of 'rapid longitudinal shortening', a simplified software-independent measure of longitudinal left ventricular (LV) deformation, (ii) correlation and agreement of rapid longitudinal shortening and feature tracking (FT) strain, and (iii) their respective prognostic value. METHODS AND RESULTS: Two rapid longitudinal shortening [long-axis shortening (LS), atrioventricular junction shortening (AVJS)] and three FT strain measures [global longitudinal strain (GLS); global circumferential strain; global radial strain] were derived. Correlation and agreement were assessed using Pearson's correlation and Bland-Altman plots. Incident events were prospectively tracked over 4.4 (3.6, 5.9) years. The association of deformation metrics with incident outcomes [heart failure (HF), myocardial infarction, stroke, cardiovascular death] was evaluated using Cox regression, adjusting for demographics, lifestyle, clinical factors, LV ejection fraction, and LV mass. The analysis included 45 844 participants (52% females, median 65 years). LS and AVJS showed moderately strong correlation and agreement with GLS. LS, AVJS, and GLS were independently associated with morbidity and mortality outcomes after adjustment. Rapid longitudinal shortening showed comparable predictive value vs. FT strain for incident cardiovascular outcomes: Hazard ratio for incident HF was 0.78 {confidence interval [CI] (0.69-0.88), 0.79 (CI 0.71-0.89), and 0.78 (CI 0.69-0.89)} for AVJS, LS, and GLS respectively. CONCLUSION: Rapid longitudinal shortening metrics are significant predictors of cardiovascular outcomes comparable to FT strain. Rapid longitudinal shortening is a simple, potentially software- and vendor-independent alternative to FT strain.