Catheter ablation versus medical therapy for atrial fibrillation with prior stroke history:a prospective propensity score-matched cohort study

BACKGROUND Patients with atrial fibrillation(AF)and prior stroke history have a high risk of cardiovascular events despite anticoagulation therapy.It is unclear whether catheter ablation(CA)has further benefits in these patients.METHODS AF patients with a previous history of stroke or systemic embolism(SE)from the prospective Chinese Atrial Fibrillation Registry study between August 2011 and December 2020 were included in the analysis.Patients were matched in a 1:1 ratio to CA or medical treatment(MT)based on propensity score.The primary outcome was a composite of all-cause death or ischemic stroke(IS)/SE.RESULTS During a total of 4.1±2.3 years of follow-up,the primary outcome occurred in 111 patients in the CA group(3.3 per 100 person-years)and in 229 patients in the MT group(5.7 per 100 person-years).The CA group had a lower risk of the primary outcome compared to the MT group[hazard ratio(HR)=0.59,95%CI:0.47–0.74,P<0.001].There was a significant decreasing risk of all-cause mortality(HR=0.43,95%CI:0.31–0.61,P<0.001),IS/SE(HR=0.73,95%CI:0.54–0.97,P=0.033),cardiovascular mortality(HR=0.32,95%CI:0.19–0.54,P<0.001)and AF recurrence(HR=0.33,95%CI:0.30–0.37,P<0.001)in the CA group compared to that in the MT group.Sensitivity analysis generated consistent results when adjusting for time-dependent usage of anticoagulants.CONCLUSIONS In AF patients with a prior stroke history,CA was associated with a lower combined risk of all-cause death or IS/SE.Further clinical trials are warranted to confirm the benefits of CA in these patients.

Drug-coated balloons for the treatment of ostial left anterior descending or ostial left circumflex artery lesions:a patientlevel propensity score-matched analysis

BACKGROUND Controversy exists as to the optimal treatment approach for ostial left anterior descending(LAD)or ostial left circumflex artery(LCx)lesions.Drug-coated balloons(DCB)may overcome some of the limitations of drug-eluting stents(DES).Therefore,we investigated the security and feasibility of the DCB policy in patients with ostial LAD or ostial LCx lesions,and compared it with the conventional DES-only strategy.METHODS We retrospectively enrolled patients with de novo ostial lesions in the LAD or LCx who underwent interventional treatment.They were categorized into two groups based on their treatment approach:the DCB group and the DES group.The treatment strategies in the DCB group involved the use of either DCB-only or hybrid strategies,whereas the DES group utilized crossover or precise stenting techniques.Two-year target lesion revascularization was the primary endpoint,while the rates of major adverse cardiovascular events,cardiac death,target vessel myocardial infarction,and vessel thrombosis were the secondary endpoints.Using propensity score matching,we assembled a cohort with comparable baseline characteristics.To ensure result analysis reliability,we conducted sensitivity analyses,including interaction,and stratified analyses.RESULTS Among the 397 eligible patients,6.25%of patients who were planned to undergo DCB underwent DES.A total of 108 patients in each group had comparable propensity scores and were included in the analysis.Two-year target lesion revascularization occurred in 5 patients(4.90%)and 16 patients(16.33%)in the DCB group and the DES group,respectively(odds ratio=0.264,95%CI:0.093–0.752,P=0.008).Compared with the DES group,the DCB group demonstrated a lower major adverse cardiovascular events rate(7.84%vs.19.39%,P=0.017).However,differences with regard to cardiac death,non-periprocedural target vessel myocardial infarction,and definite or probable vessel thrombosis between the groups were non-significant.CONCLUSIONS The utilization of the DCB approach signifies an innovative and discretionary strategy for managing isolated ostial lesions in the LAD or LCx.Nevertheless,a future randomized trial investigating the feasibility and safety of DCB compared to the DES-only strategy specifically for de novo ostial lesions in the LAD or LCx is highly warranted.

Effect of advanced age on plasma homocysteine levels and its association with ischemic stroke in non-valvular atrial fibrillation

BackgroundElevated homocysteine (Hcy ) 被报导了在 atrial 与心血管的事件被联系纤维性颤动(AF ) 病人，当在 AF 的血浆 Hcy 的年龄相关的表示模式仍然保持未知时。学习被瞄准与非瓣膜的 AF 在 2562 个连续病人全部的非瓣膜的 AF patients.MethodsA 与 ischemic 击在血浆 Hcy 层次和它的协会上调查先进年龄的效果， 535 控制被注册并且把年龄组划分了成六。血浆 Hcy 层次在不同年龄组之中被分析，并且 Hcy 上的先进年龄的效果是 investigated.ResultsPlasma Hcy 层次没证明在组之中的任何差别在 65 年下面变老，当它 65-74 年并且超过 75 年在病人严厉地增加了时(15.

Promising xenograft animal model recapitulating the features of human pancreatic cancer

BACKGROUND Multiple sites of metastasis and desmoplastic reactions in the stroma are key features of human pancreatic cancer(PC).There are currently no simple and reliable animal models that can mimic these features for accurate disease modeling.AIM To create a new xenograft animal model that can faithfully recapitulate the features of human PC.METHODS Interleukin 2 receptor subunit gamma(IL2RG)gene knockout Syrian hamster was created and characterized.A panel of human PC cell lines were transplanted into IL2RG knockout Syrian hamsters and severe immune-deficient mice subcutaneously or orthotopically.Tumor growth,local invasion,remote organ metastasis,histopathology,and molecular alterations of tumor cells and stroma were compared over time.RESULTS The Syrian hamster with IL2RG gene knockout(named ZZU001)demonstrated an immune-deficient phenotype and function.ZZU001 hamsters faithfully recapitulated most features of human PC,in particular,they developed metastasis at multiple sites.PC tissues derived from ZZU001 hamsters displayed desmoplastic reactions in the stroma and epithelial to mesenchymal transition phenotypes,whereas PC tissues derived from immune-deficient mice did not present such features.CONCLUSION ZZU001 hamsters engrafted with human PC cells are a superior animal model compared to immune-deficient mice.ZZU001 hamsters can be a valuable animal model for better understanding the molecular mechanism of tumorigenesis and metastasis and the evaluation of new drugs targeting human PC.

Catheter ablation for atrial fibrillation is associated with reduced risk of mortality in the elderly:a prospective cohort study and propensity score analysis

Background It is unclear whether catheter ablation(CA)for atrial fibrillation(AF)affects the long-term prognosis in the elderly.This study aims to evaluate the relationship between CA and long-term outcomes in elderly patients with AF.Methods Patients more than 75 years old with non-valvular AF were prospectively enrolled between August 2011 and December 2017 in the Chinese Atrial Fibrillation Registry Study.Participants who underwent CA at baseline were propensity score matched(1:1)with those who did not receive CA.The outcome events included all-cause mortality,cardiovascular mortality,stroke/transient ischemic attack(TIA),and cardiovascular hospitalization.Results Overall,this cohort included 571 ablated patients and 571 non-ablated patients with similar characteristics on 18 dimensions.During a mean follow-up of 39.75±19.98 months(minimum six months),24 patients died in the ablation group,compared with 60 deaths in the non-ablation group[hazard ratio(HR)=0.49,95%confidence interval(CI):0.30-0.79,P=0.0024].Besides,6 ablated and 29 non-ablated subjects died of cardiovascular disease(HR=0.25,95%CI:0.11-0.61,P=0.0022).A total of 27 ablated and 40 non-ablated patients suffered stroke/TIA(HR=0.79,95%CI:0.48-1.28,P=0.3431).In addition,140 ablated and 194 non-ablated participants suffered cardiovascular hospitalization(HR=0.84,95%CI:0.67-1.04,P=0.1084).Subgroup analyses according to gender,type of AF,time since onset of AF,and anticoagulants exposure in initiation did not show significant heterogeneity.Conclusions In elderly patients with AF,CA may be associated with a lower incidence of all-cause and cardiovascular mortality.

Chronic kidney disease and risks of adverse clinical events in patients with atrial fibrillation

BACKGROUND Chronic kidney disease(CKD)is highly prevalent in patients with atrial fibrillation(AF).However,the asso-ciation between CKD and clinical consequences in AF patients is still under debate.METHODS We included 19,079 nonvalvular AF patients with available estimated glomerular filtration rate(eGFR)values in the Chinese Atrial Fibrillation Registry from 2011 to 2018.Patients were classified into no CKD(eGFR≥90 mL/min per 1.73 m2),mild CKD(60≤eGFR<90 mL/min per 1.73 m2),moderate CKD(30≤eGFR<60 mL/min per 1.73 m2),and severe CKD(eGFR<30 mL/min per 1.73 m2)groups.The risks of thromboembolism,major bleeding,and cardiovascular mortality were estimated with Fine-Gray regression analysis according to CKD status.Cox regression was performed to assess the risk of all-cause mortal-ity associated with CKD.RESULTS Over a mean follow-up of 4.1±1.9 years,there were 985 thromboembolic events,414 major bleeding events,956 car-diovascular deaths,and 1,786 all-cause deaths.After multivariate adjustment,CKD was not an independent risk factor of throm-boembolic events.As compared to patients with no CKD,those with mild CKD,moderate CKD,and severe CKD had a 45%,47%,and 133%higher risk of major bleeding,respectively.There was a graded increased risk of cardiovascular mortality associated with CKD status compared with no CKD group:adjusted hazard ratio[HR]was 1.34(95%CI:1.07−1.68,P=0.011)for mild CKD group,2.17(95%CI:1.67−2.81,P<0.0001)for moderate CKD group,and 2.95(95%CI:1.97−4.41,P<0.0001)for severe CKD group,respectively.Risk of all-cause mortality also increased among patients with moderate or severe CKD.CONCLUSIONS CKD status was independently associated with progressively higher risks of major bleeding and mortality,but didn’t seem to be an independent predictor of thromboembolism in AF patients.

Fully Automatic Scar Segmentation for Late Gadolinium Enhancement MRI Images in Left Ventricle with Myocardial Infarction

Numerous methods have been published to segment the infarct tissue in theleft ventricle, most of them either need manual work, post-processing, or suffer from poorreproducibility. We proposed an automatic segmentation method for segmenting the infarct tissue irleft ventricle with myocardial infarction. Cardiac images of a total of 60 diseased hearts (55 humanhearts and 5 porcine hearts) were used in this study. The epicardial and endocardial boundariesof the ventricles in every 2D slice of the cardiac magnetic resonance with late gadoliniumenhancement images were manually segmented. The subsequent pipeline of infarct tissuesegmentation is fully automatic. The segmentation results with the automatic algorithm proposed inthis paper were compared to the consensus ground truth. The median of Dice overlap between ourautomatic method and the consensus ground truth is 0.79. We also compared the automatic methodwith the consensus ground truth using different image sources from diferent centers with diferentscan parameters and different scan machines. The results showed that the Dice overlap with thepublic dataset was 0.83, and the overall Dice overlap was 0.79. The results show that our method isrobust with respect to different MRI image sources, which were scanned by different centers withdifferent image collection parameters. The segmentation accuracy we obtained is comparable toor better than that of the conventional semi-automatic methods. Our segmentation method may beuseful for processing large amount of dataset in clinic.

Analysis of Coronary Angiography Video Interpolation Methods to Reduce X-ray Exposure Frequency Based on Deep Learning

Cardiac coronary angiography is a major technique that assists physicians during interventional heart surgery.Under X-ray irradiation,the physician injects a contrast agent through a catheter and determines the coronary arteries’state in real time.However,to obtain a more accurate state of the coronary arteries,physicians need to increase the fre-quency and intensity of X-ray exposure,which will inevitably increase the potential for harm to both the patient and the surgeon.In the work reported here,we use advanced deep learning algorithms to fi nd a method of frame interpola-tion for coronary angiography videos that reduces the frequency of X-ray exposure by reducing the frame rate of the coronary angiography video,thereby reducing X-ray-induced damage to physicians.We established a new coronary angiography image group dataset containing 95,039 groups of images extracted from 31 videos.Each group includes three consecutive images,which are used to train the video interpolation network model.We apply six popular frame interpolation methods to this dataset to confi rm that the video frame interpolation technology can reduce the video frame rate and reduce exposure of physicians to X-rays.

A simple and easily implemented risk model to predict 1-year ischemic stroke and systemic embolism in Chinese patients with atrial fibrillation

Background:Accurate prediction of ischemic stroke is required for deciding anticoagulation use in patients with atrial fibrillation(AF).Even though only 6%to 8%of AF patients die from stroke,about 90%are indicated for anticoagulants according to the current AF management guidelines.Therefore,we aimed to develop an accurate and easy-to-use new risk model for 1-year thromboembolic events(TEs)in Chinese AF patients.Methods:From the prospective China Atrial Fibrillation Registry cohort study,we identified 6601 AF patients who were not treated with anticoagulation or ablation at baseline.We selected the most important variables by the extreme gradient boosting(XGBoost)algorithm and developed a simplified risk model for predicting 1-year TEs.The novel risk score was internally validated using bootstrapping with 1000 replicates and compared with the CHA2DS2-VA score(excluding female sex from the CHA2DS2-VASc score).Results:Up to the follow-up of 1 year,163 TEs(ischemic stroke or systemic embolism)occurred.Using the XGBoost algorithm,we selected the three most important variables(congestive heart failure or left ventricular dysfunction,age,and prior stroke,abbreviated as CAS model)to predict 1-year TE risk.We trained a multivariate Cox regression model and assigned point scores proportional to model coefficients.The CAS scheme classified 30.8%(2033/6601)of the patients as low risk for TE(CAS score=0),with a corresponding 1-year TE risk of 0.81%(95%confidence interval[CI]:0.41%–1.19%).In our cohort,the C-statistic of CAS model was 0.69(95%CI:0.65–0.73),higher than that of CHA2DS2-VA score(0.66,95%CI:0.62–0.70,Z=2.01,P=0.045).The overall net reclassification improvement from CHA2DS2-VA categories(low=0/high≥1)to CAS categories(low=0/high≥1)was 12.2%(95%CI:8.7%–15.7%).Conclusion:In Chinese AF patients,a novel and simple CAS risk model better predicted 1-year TEs than the widely-used CHA2DS2-VA risk score and identified a large proportion of patients with low risk of TEs,which could potentially improve anticoagulation decision-making.Trial Registration:www.chictr.org.cn(Unique identifier No.ChiCTR-OCH-13003729).

Association between use of amiodarone for non-valvular atrial fibrillation and patient survival:from the prospective China Atrial Fibrillation Registry

Background:Post hoc analysis of the landmark atrial fibrillation follow-up investigation of rhythm management trial revealed that amiodarone was associated with higher risks of mortality,intensive care unit admission,and non-cardiovascular death.We aim to evaluate the association between amiodarone use and patient survival under updated medical mode and level using data from the China Atrial Fibrillation(China-AF)Registry study.Methods:Clinical data of 8161 non-valvular atrial fibrillation(NVAF)patients who were antiarrhythmic drug(AAD)-naive before enrollment into the China-AF Registry,recruited between August 2011 and February 2017,were collected.The primary outcome was all-cause mortality.A Cox proportional hazard regression model was used to evaluate the association between amiodarone use and the outcome.We also calculated the rate of sinus rhythm maintenance at the penultimate follow-up.Results:Compared with 6167 patients of non-AAD group,689 patients of the amiodarone group were younger(mean age 65.6vs.68.6 years),more frequently completed high school education,had fewer comorbidities such as chronic heart failure,prior bleeding,and stroke,and were more likely to be treated in tertiary hospitals while less hospitalization.The proportion of persistent AF was much lower among users of amiodarone,who were also less likely to be taking oral anticoagulants.The patients in the amiodarone group had a statistically insignificant lower incidence of all-cause mortality(2.44vs.3.91 per 100 person-years)over a mean follow-up duration of 300.6±77.5 days.After adjusting for potential confounders,amiodarone use was not significantly associated with a lower risk of all-cause mortality(adjusted hazard ratio,0.79;95%confidence interval,0.42-1.49).Sub-group analysis revealed the consistent results.The rate of sinus rhythm maintenance at the penultimate follow-up in the amiodarone group was significantly higher than in the non-AAD group.Conclusions:Our study indicated that amiodarone use was not significantly associated with a lower risk of 1-year all-cause mortality compared with a non-AAD strategy in"real-world"patients with NVAF.

In-hospital direct costs for thromboembolism and bleeding in Chinese patients with atrial fibrillation

Objective: Limited data are available on the direct costs of hospitalization owing to thromboembolism and bleeding in patients with atrial fibrillation (AF) in China. Such data are essential for policy development, service planning, and cost-effectiveness analysis of new therapeutic strategies. This study aimed to provide detailed data regarding in-hospital direct costs for these pa-tients, compare the costs at different scenarios, and identify independent factors that may predict the costs. Methods: We collected data regarding in-hospital direct costs among patients with AF who were hospitalized owing to ischemic stroke (IS), transient ischemic attack (TIA), intracranial hemorrhage (ICH), or major gastrointestinal bleeding. All data were collected from 7 representative tertiary referral hospitals and 3 secondary care hospitals from December 2009 to October 2014. Results: In total, 312 eligible patients with thromboembolism and 143 patients with major bleeding were identified, and their hospital charts were reviewed. The median in-hospital direct costs were 17,857 Chinese Yuan (CNY) for IS and 16,589 CNY for TIA (equivalent to 2907 US dollars and 2701 US dollars, respectively). For patients with major bleeding, the costs were 27,924 CNY for ICH and 18,196 CNY for major gastrointestinal bleeding (equivalent to 4546 US dollars and 2962 US dollars, respec-tively). The direct costs were mainly driven by medications, which accounted for approximately 33.4%-36.1% in different groups of patients. The direct costs were highly related to the hospital level and National Institutes of Health Stroke Scale scores in patients with thromboembolism; in patients with ICH, the factors included hospital level, warfarin treatment before admission, and prior hospitalization for stroke. Conclusions: Given the high prevalence, AF-related thromboembolism and bleeding impose considerable economic burden on the Chinese society. Efforts to improve the management of AF may confer substantial economic benefits.

Association of interleukin-18 gene polymorphisms with Takayasu arteritis in a Chinese Han population

Background:Interleukin-18(IL18)gene polymorphisms are related to many inflammatory and autoimmune diseases.However,a correlation analysis between IL18-607C/A and-137G/C gene polymorphisms and Takayasu arteritis(TA)is lacking.Methods:This study enrolled 200 patients with TA as the case group and 334 region-,age-,and sex-matched healthy subjects as the control group.We genotyped alleles and genotypes at positions-607 and-137 of the IL18 gene and analyzed the distribution frequencies.Mann-Whitney U test,t test,Chi-squared test and Hardy-Weinberg equilibrium were performed.Results:After adjusting for risk factors,the adjusted odds ratios and 95%confidence intervals at position-607C/A were 0.533,0.391 to 0.880(P=0.010);0.266,0.586 to 1.002(P=0.051);and 0.122,0.552 to 1.420(P=0.613)under the dominant,additive,and recessive models,respectively.For the-137G/C polymorphism,the adjusted odds ratios and 95%confidence intervals were 1.571,1.068 to 2.311(P=0.022);1.467,1.086 to 1.980(P=0.012);and 1.815,0.901 to 3.656(P=0.095)under the dominant,additive,and recessive models,respectively.Moreover,regardless of the model used,we found no statistical difference in distribution frequency between the active and quiescent states of TA for the-607C/A(P=0.355,0.631,and 0.705,respectively)and-137G/C polymorphisms(P=0.205,0.385,and 0.208,respectively).Conclusions:The IL18-607C/A gene polymorphism may decrease the risk of TA,and thus is a protective factor,whereas-137G/C may increase the risk of TA,and thus is a risk factor.However,neither polymorphism was related to activity(active vs.quiescent)of TA.

A new surgical technique for post-myocardial infarction ventricular septal rupture with hemodynamic instability

Ventricular septal rupture(VSR)is a rare but lethal complication of acute myocardial infarction(AMI).[1]Emergent repair surgery provides the only chance for survival for patients with VSR;however,the perioperative mortality rate remains extremely high at the early phase.[2] Elective surgery is widely utilized in real-world clinical practice and is associated with improved prognosis.[3] Nevertheless,the results of elective surgery might be a manifestation of survival bias,as it is usually performed in relatively stable patients with VSR who are expected to survive the early stage and have a better prognosis than patients complicated with hemodynamic instability in the early stage.[4]In this study,we aimed to present a novel surgical repair technique that can be safely,feasibly,and effectively used in hemodynamically unstable patients with VSR in the acute phase and to report the preliminary results.

Temporal trends in diagnosis,treatment,and outcome for non-ST-segment elevation acute coronary syndrome in three regions of China,2008–2015

To the Editor:As acute coronary syndromes(ACS)is common causes of morbidity and mortality in China,they serve as an important case example to assess the impact of these health reforms on the quality,safety,and efficiency of healthcare.[1]ACS comprises a wide spectrum of disease subgroups,including ST-segment elevation myocardial infarction(STEMI),unstable angina(UA),and non-ST-segment elevation myocardial infarction(NSTEMI).Previous studies have shown increases in the intensity of testing and treatment while stable in-hospital mortality for STEMI in China between 2001 and 2011.[2]As non-ST-segment elevation acute coronary syndrome(NSTE-ACS)patients,who account for about two-thirds of ACS patients,have a wide spectrum of disease severity,risk-stratified management is recommended to ensure appropriate allocation of resources,especially in limited-resource settings of China.As limited data exist on the use of medical services and clinical outcomes in relation to health reforms,we aimed to determine temporal trends in diagnosis,treatment,and outcome for hospitalized NSTE-ACS patients in three regions of China between 2008 and 2015.

Dabigatran-induced esophageal injury:a case report

To the Editor:Atrial fibrillation(AF)is one of the leading risk factors for stroke and is associated with a fivefold increase in the incidence of stroke.For years,warfarin has been prescribed to lower the thrombotic risk in patients with AF.However,because of the finicky nature of warfarin(ie,unpredictable pharmacokinetics,frequent international normalized ratio testing,complex food-drug interactions,etc.),it has been incrementally replaced by multiple direct oral anticoagulants(DOACs).Dabigatran,a potent,competitive,and reversible DOAC that directly targets thrombin,was approved by the US Food and Drug Administration in 2010 as an alternative antithrombotic option for nonvalvular AF.While the randomized evaluation of long-term anticoagulation therapy(RE-LY)trial(a noninferiority trial comparing warfarin with dabigatran in patients with AF)showed that dabigatran is as successful as warfarin for preventing stroke or systemic embolism,its adverse effects also need attention.[1]Accumulating case reports have attracted attention to the issue of dabigatran-induced esophagitis(DIE).[2,3]Recent studies have found that elderly patients are more likely to develop DIE.[4]However,herein,we present a case of a younger male who developed DIE after taking dabigatran.