Atrial Fibrillation NETwork

Up to one third of patients with an implantable cardioverter defibrillator (ICD) experience shock discharges in the last 24 h before death, which no longer have any therapeutic benefit. Even in patients who have aliving will (do not resuscitate, DNR, directive), the shock function of the ICD is activated in over 50% of those affected 24 h before death. Asignificant subgroup of ICD wearers must therefore experience painful, significantly stressful and unnecessary ICD shocks at the hour of their death. All available position papers on this topic call for patients to be informed about this issue in good time; however, in reality such aconversation almost never takes place. This paper outlines the legal basis that helps doctors to deactivate the ICD in the final stage of life and the specific conditions that must be met. This paper advocates repeatedly addressing the issue during the course of the illness and to involve relatives. The actual conversation about deactivation at the end of life should be proactively initiated by the responsible attending physician and should take the form of astructured, patient-centered dialogue in the spirit of good dialogue.

AimsPatients with device-detected atrial fibrillation (DDAF) have a lower stroke risk than those with ECG-diagnosed AF, requiring careful evaluation of oral anticoagulation benefits vs. its inherent bleeding risk.Methods and resultsAn unmatched win ratio analysis was performed of the NOAH-AFNET 6 trial dataset, using components of the primary efficacy and safety outcomes of the trial. The primary analysis used this hierarchical order: (1) all-cause death, (2) stroke, (3) systemic or pulmonary embolism/myocardial infarction, and (4) major bleeding. Two additional analyses replaced all-cause death with cardiovascular death or included patient-reported outcomes. Win odds were calculated to account for undecided comparisons. Among 2534 patients 77 ± 7 years old, 947 (37%) women, median CHA2DS2-VA score 3 [interquartile range (IQR), 3–4], median follow-up 21 months (IQR, 10–38) 1 605 280 win ratio pairs were analyzed. The win ratio comparing edoxaban to no anticoagulation was 0.87 (95% CI: 0.68–1.10; P = 0.23). Most comparisons resulted in no clear winner (undecided pairs 84.9%). In the remaining comparisons, edoxaban won in 46% of the cases, placebo in 54%. Death and major bleeding were the most common events. The win odds was 0.98 (95% CI: 0.94–1.01; P = 0.23).ConclusionsThis hypothesis-generating win ratio analysis, integrating death, thrombotic events, and major bleeds with and without quality of life, did not find an advantage of anticoagulation with edoxaban over no anticoagulation in patients with DDAF. The most common events were death and major bleeding.

Clinical concerns exist about the potential proarrhythmic effects of the sodium channel blockers (SCBs) flecainide and propafenone in patients with cardiovascular disease. Sodium channel blockers were used to deliver early rhythm control (ERC) therapy in EAST-AFNET 4. We analysed the primary safety outcome (death, stroke, or serious adverse events related to rhythm control therapy) and primary efficacy outcome (cardiovascular death, stroke, and hospitalization for worsening of heart failure (HF) or acute coronary syndrome) during SCB intake for patients with ERC (n = 1395) in EAST-AFNET 4. The protocol discouraged flecainide and propafenone in patients with reduced left ventricular ejection fraction and suggested stopping therapy upon QRS prolongation >25% on therapy. Flecainide or propafenone was given to 689 patients [age 69 (8) years; CHA2DS2-VASc 3.2 (1); 177 with HF; 41 with prior myocardial infarction, coronary artery bypass graft, or percutaneous coronary intervention; 26 with left ventricular hypertrophy >15 mm; median therapy duration 1153 [237, 1828] days]. The primary efficacy outcome occurred less often in patients treated with SCB [3/100 (99/3316) patient-years] than in patients who never received SCB [SCBnever 4.9/100 (150/3083) patient-years, P < 0.001]. There were numerically fewer primary safety outcomes in patients receiving SCB [2.9/100 (96/3359) patient-years] than in SCBnever patients [4.2/100 (135/3220) patient-years, adjusted P = 0.015]. Sinus rhythm at 2 years was similar between groups [SCB 537/610 (88); SCBnever 472/579 (82)]. Long-term therapy with flecainide or propafenone appeared to be safe in the EAST-AFNET 4 trial to deliver effective ERC therapy, including in selected patients with stable cardiovascular disease such as coronary artery disease and stable HF. Clinical Trial Registration ISRCTN04708680, NCT01288352, EudraCT2010-021258-20, www.easttrial.org.

Mosquitoes are one of the main vectors of many important diseases and their degree of resistance to chemical insecticides has increased. Nowadays, it has become crucial to identify novel plant larvicides with an eco-friendly impact. The components of essential oils from Croton linearis Jacq. (EO-Cl), Lantana involucrata L. (EO-Li), Ocimum sanctum var. cubensis M. Gómez. (EO-Os), and Zanthoxylum pistaciifolium Griseb. (syn. Zanthoxylum flavum subsp. pistaciifolium (Griseb.) Reynel (EO-Zp) were determined using gas chromatography-mass spectrometry (GC–MS) analysis. Larvicidal and adulticidal bioassays against Aedes aegypti, Anopheles albitarsis and Culex quinquefasciatus, were performed according to the World Health Organization standard methods. A high diversity of compounds was identified in the four oils, with a total of 152 compounds (33–70 components). EO-Cl, EO-Li, and EO-Os were classified as active against both insect forms, larvae and adults. Lantana involucrata showed the best results, with LC50 values from 33.8 to 41.7 mg/L. In most of the cases, it was not possible to associate the main compounds with the measured activity, supporting the hypothesis about probable synergistic interactions among major and minor compounds. The results indicate EO-Cl, EO-Os, and EO-Li as good eco-friendly insecticides with potential.

The objective of this paper is to propose a technical solution for fully automated overhead line inspection triggered by electrical fault. The developed system comprises of traveling wave measurement technology for fault locating, an unmanned aerial vehicle (UAV) equipped with photo and video cameras for remote line inspection, an information and communication technology infrastructure for data exchange between system components, an on-premise control server for flight mission generation and a trained deep learning classifier for both asset detection and health state classification. The main system components as well as the overall process of mission generation and execution are described in detail. This also includes the applied solution for image processing and inspection report generation. Finally, the recorded data and field test results of more than two years, including two successful test flights beyond visual line of sight, are discussed.

We describe the first case of the use of pulsed-field ablation (PFA) to treat focal atrial tachycardia (FAT) in a pediatric patient. An 11-year-old girl with obesity was referred to our center for ablation of incessant atrial tachycardia. The earliest atrial activation was shown to be present in the left superior pulmonary vein. Radiofrequency ablation of FAT seems to be associated with a lower success rate and, especially, with a higher complication rate than in adult patients. We performed ablation by means of a novel nonthermal energy source (PFA) that is able to reduce the risk of complications due to injury to anatomic structures surrounding the heart. After the first application, stable sinus rhythm was restored. PFA can be used to treat FAT arising from pulmonary veins in young children as a good alternative to RFA ablation, thereby reducing the risk of potential procedure-related complications.

The Covid-19 pandemic during its early phases posed significant psychological threats particularly for medical frontline personal. It is unclear whether the medical workforce with the passage of time has adapted to these threats or have generalized to wider medical settings. An online survey was conducted reaching 1476 physicians in Germany with valid data from 1327 participants. Depression and anxiety were screened with the PHQ-2 and the GAD-2. Among a subtotal of 1139 (86.6%) physicians reporting personal treatment experiences with Covid-19 patients, 553 (84.8%) worked in a private practice (PP) and 586 (88.3%) in a hospital (HP). Covid-19 provoked profound conflicts between professional and ethical values: more physicians in PPs than HPs reported external constraints on their medical care being in conflict with the code of medical ethics (39.1 vs. 34.4%, p < 0.002) and significantly more HPs failed to maintain the dignity of their patients during the pandemic (48 vs. 27%, p < 0.0001). Comparison with reference groups among physicians with comparable size and settings during the first wave of Covid-19 revealed a significant increase in the prevalence of depression (23.0%) and anxiety (24.16%). Feelings of helplessness (63.3% in HPs and 53.4% in PPs) were associated with female sex, minor years of medical experience, sleeping problems and being encountered to unsettling events. Exposure to unsettling events and helplessness was significantly mediated by sleep disturbances (ß = 0.29, SE = 0.03, p < 0.0001). Covid-19 induced stress job content issues have broadened to medical disciplines beyond frontline workers. Emotional perturbations among physicians have attained a critical magnitude.

Non-vitamin K oral anticoagulants have become the standard therapy for preventing stroke and ischemic thromboembolism in most patients with atrial fibrillation (AF). The effectiveness and safety of non-vitamin K oral anticoagulants in patients on hemodialysis is not well known. From June 2017 through May 2022, AXADIA-AFNET 8 (Compare Apixaban and Vitamin K Antagonists in Patients With Atrial Fibrillation and End-Stage Kidney Disease), an investigator-initiated PROBE (prospective randomized open blinded end point) outcome assessment trial, randomized patients with AF on chronic hemodialysis to either apixaban (2.5 mg BID) or the vitamin K antagonist (VKA) phenprocoumon (international normalized ratio, 2.0 to 3.0). The composite primary safety outcome was defined by a first event of major bleeding, clinically relevant nonmajor bleeding, or all-cause death. The primary efficacy outcome was a composite of ischemic stroke, all-cause death, myocardial infarction, and deep vein thrombosis or pulmonary embolism. Our hypothesis was that apixaban is noninferior to VKA. Thirty-nine sites randomized 97 patients (30% women; mean age 75 years; mean CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, female sex] score, 4.5; baseline characteristics balanced between groups): 48 to apixaban and 49 to VKA. The median follow-up time was 429 days (range, 37 to 1370) versus 506 days (range, 101 to 1379), respectively. Adherence to apixaban was >80% in 44 of 48 patients; the median time in therapeutic range on VKA was 50.7%. Composite primary safety outcome events occurred in 22 patients (45.8%) on apixaban and in 25 patients (51.0%) on VKA (hazard ratio, 0.93 [95% CI, 0.53-1.65]; Pnoninferiority=0.157). Composite primary efficacy outcome events occurred in 10 patients (20.8%) on apixaban and in 15 patients (30.6%) on VKA (P=0.51; log rank). There were no significant differences regarding individual outcomes (all-cause mortality, 18.8% versus 24.5%; major bleeding, 10.4% versus 12.2%; and myocardial infarction, 4.2% versus 6.1%, respectively). In this randomized trial comparing apixaban and VKA in patients with AF on hemodialysis with long follow-up, no differences were observed in safety or efficacy outcomes. Even on oral anticoagulation, patients with AF on hemodialysis remain at high risk of cardiovascular events. Larger randomized trials are needed to determine the optimal anticoagulation regimen for patients with AF on hemodialysis. URL: https://www. gov; Unique identifier: NCT02933697.

While augmented reality (AR) gets established in many use cases in the broad field of industrial, education, and entertainment applications, so far, AR has not been used in gas pressure regulation stations (GPRS). In an iterative co-design process, we have developed a first AR prototype to support maintenance work in such GPRS environments. Together with different stakeholders, in particular the technical staff as potential end-users, we discussed and gathered the requirements, observed workers interacting with the AR prototype on-site, and collected feedback, but also identified problems and limitations. Eventually, we deduced two challenging use cases, (i) displaying expandable 3D models of the components built into the station, and (ii) digitizing an inspection form in AR to facilitate the inspection task. We describe the co-design process, its findings, and introduce lessons-learned for the resulting AR prototype.

AimsA strategy of systematic, early rhythm control (ERC) improves cardiovascular outcomes in patients with atrial fibrillation (AF). It is not known how this outcome-reducing effect is mediated.Methods and resultsUsing the Early treatment of Atrial Fibrillation for Stroke prevention Trial (EAST—AFNET 4) data set, potential mediators of the effect of ERC were identified in the total study population at 12-month follow up and further interrogated by use of a four-way decomposition of the treatment effect in an exponential model predicting future primary outcome events. Fourteen potential mediators of ERC were identified at the 12-month visit. Of these, sinus rhythm at 12 months explained 81% of the treatment effect of ERC compared with usual care during the remainder of follow up (4.1 years). In patients not in sinus rhythm at 12 months, ERC did not reduce future cardiovascular outcomes (hazard ratio 0.94, 95% confidence interval 0.65–1.67). Inclusion of AF recurrence in the model only explained 31% of the treatment effect, and inclusion of systolic blood pressure at 12 months only 10%. There was no difference in outcomes in patients who underwent AF ablation compared with those who did not undergo AF ablation.ConclusionThe effectiveness of early rhythm control is mediated by the presence of sinus rhythm at 12 months in the EAST-AFNET 4 trial. Clinicians implementing ERC should aim for rapid and sustained restoration of sinus rhythm in patients with recently diagnosed AF and cardiovascular comorbidities.