Journal: Europace

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Abstract

EHRA expert consensus statement and practical guide on optimal implantation technique for conventional pacemakers and implantable cardioverter-defibrillators: endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin-American Heart Rhythm Society (LAHRS).

Burri H, Starck C, Auricchio A, Biffi M, ... Vassilikos VP, Martins Oliveira M
With the global increase in device implantations, there is a growing need to train physicians to implant pacemakers and implantable cardioverter-defibrillators. Although there are international recommendations for device indications and programming, there is no consensus to date regarding implantation technique. This document is founded on a systematic literature search and review, and on consensus from an international task force. It aims to fill the gap by setting standards for device implantation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 19 Apr 2021; epub ahead of print
Burri H, Starck C, Auricchio A, Biffi M, ... Vassilikos VP, Martins Oliveira M
Europace: 19 Apr 2021; epub ahead of print | PMID: 33878762
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Abstract

Emerging evidence for a mechanistic link between low-frequency oscillation of ventricular repolarization measured from the electrocardiogram T-wave vector and arrhythmia.

Taggart P, Pueyo E, Duijvenboden SV, Porter B, ... Gill JS, Lambiase P
Strong recent clinical evidence links the presence of prominent oscillations of ventricular repolarization in the low-frequency range (0.04-0.15 Hz) to the incidence of ventricular arrhythmia and sudden death in post-MI patients and patients with ischaemic and non-ischaemic cardiomyopathy. It has been proposed that these oscillations reflect oscillations of ventricular action potential duration at the sympathetic nerve frequency. Here we review emerging evidence to support that contention and provide insight into possible underlying mechanisms for this association.

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Europace: 19 Apr 2021; epub ahead of print
Taggart P, Pueyo E, Duijvenboden SV, Porter B, ... Gill JS, Lambiase P
Europace: 19 Apr 2021; epub ahead of print | PMID: 33880542
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Abstract

Peculiarities in coronary sinus anatomy: implications for successful cannulation from an autoptic study.

Sławek-Szmyt S, Szmyt K, Żaba C, Grygier M, Lesiak M, Araszkiewicz A
Aims
The number of cardiovascular procedures using the coronary sinus (CS) as a gateway is constantly increasing. The present study aimed to define specific structures within CS, which could potentially complicate CS cannulation and to develop a new Thebesian valve (TV) classification system.
Methods and results
The study was performed on 560 consecutive unfixed cadaveric hearts during routine autopsy examination (1-3 days post-mortem). Basic CS dimensions were measured and the presence and dimensions of the TV and the Vieussens valve (VV) were assessed. Thebesian valves were classified according to their morphology into six main types: remnant fold, semilunar, fenestrated, chord, fused strands, and mixed shaped. The median age of hearts was 48 years (range 16-95 years), and 38.9% were female. Thebesian valve was present in 79.5%. The most common TV type was semilunar (54%) followed by fenestrated (8.2%), remnant fold (5.5%), fused strands (4.8%), chord (4.0%), and mixed shaped (3.0%). In 1.1% of hearts, TV totally covered the coronary sinus ostium (CSO). The VV was detected in 67.9%. Potentially occlusive VV was found in 1.1% hearts and in all of which it coexisted with obstructive TV. The median CSO area was 87.9 mm2 [interquartile range (IQR): 56.5-127.1 mm2] and median CS length was 38 mm (IQR: 29.5-45 mm). The CSO area and CS length correlated with each other and with the right atrium\'s dimensions.
Conclusion
We identified six types of TVs, among which only 1.1% TVs caused total occlusion of CSO. The obstructive TV co-existed with potentially occlusive VV what might hinder CS cannulation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 16 Apr 2021; epub ahead of print
Sławek-Szmyt S, Szmyt K, Żaba C, Grygier M, Lesiak M, Araszkiewicz A
Europace: 16 Apr 2021; epub ahead of print | PMID: 33864081
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Abstract

Electrocardiographic recognition of benign and malignant right ventricular arrhythmias.

Lee J, Adeola O, Garan H, Stevenson WG, Yarmohammadi H
Ventricular arrhythmias (VAs) can originate from different anatomical locations of the right ventricle. Ventricular arrhythmias originating from right ventricle have unique electrocardiographic (ECG) characteristics that can be utilized to localize the origin of the arrhythmia. This is crucial in pre-procedural planning particularly for ablation treatments. Moreover, non-ischaemic structural heart diseases, such as infiltrative and congenital heart diseases, are associated with the VAs that exhibit particular ECG findings. This article comprehensively reviews discriminatory ECG characteristics of VAs in the right ventricle with and without structural right ventricular diseases.

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Europace: 16 Apr 2021; epub ahead of print
Lee J, Adeola O, Garan H, Stevenson WG, Yarmohammadi H
Europace: 16 Apr 2021; epub ahead of print | PMID: 33864080
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Abstract

Increased beat-to-beat variability of cerebral microcirculatory perfusion during atrial fibrillation: a near-infrared spectroscopy study.

Saglietto A, Scarsoglio S, Canova D, Roatta S, ... Ridolfi L, Anselmino M
Aims
Atrial fibrillation (AFib) is associated with cognitive decline/dementia, independently from clinical strokes or transient ischaemic attacks (TIA). Recent in silico data suggested that AFib may induce transient critical haemodynamic events in the cerebral microcirculation. The aim of this study is to use non-invasive spatially resolved cerebral near-infrared spectroscopy (SRS-NIRS) to investigate in vivo beat-to-beat microcirculatory perfusion during AFib and after sinus rhythm (SR) restoration.
Methods and results
Cerebral SRS-NIRS with high-frequency sampling (20 Hz) and non-invasive systemic haemodynamic monitoring were recorded before and after elective electrical cardioversion (ECV) for AFib or atrial flutter (AFL). To assess beat-to-beat effects of the rhythm status, the frequency distribution of inter-beat differences in tissue haemoglobin index (THI), a proxy of microcirculatory cerebral perfusion, was compared before and after SR restoration. Fifty-three AFib/AFL patients (mean age 69 ± 8 years, 79% males) were ultimately enrolled. Cardioversion was successful in restoring SR in 51 (96%) patients. In front of a non-significant decrease in arterial blood pressure extreme events between pre- and post-ECV measurements, a significant decrease of both hypoperfusive and hyperperfusive/hypertensive microcirculatory events was observed after SR restoration (P < 0.001 and P = 0.041, respectively).
Conclusion
The present is the first in vivo demonstration that SR restoration by ECV significantly reduces the burden of extreme single-beat haemodynamic events in cerebral microcirculation. Future studies are needed to assess whether SR maintenance might slow long-term AFib-correlated cognitive decline/dementia.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 12 Apr 2021; epub ahead of print
Saglietto A, Scarsoglio S, Canova D, Roatta S, ... Ridolfi L, Anselmino M
Europace: 12 Apr 2021; epub ahead of print | PMID: 33846732
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Abstract

MANual vs. automatIC local activation time annotation for guiding Premature Ventricular Complex ablation procedures (MANIaC-PVC study).

Jáuregui B, Fernández-Armenta J, Acosta J, Penela D, ... Pedrote A, Berruezo A
Aims
To assess potential benefits of a local activation time (LAT) automatic acquisition protocol using wavefront annotation plus an ECG pattern matching algorithm [automatic (AUT)-arm] during premature ventricular complex (PVC) ablation procedures.
Methods and results
Prospective, randomized, controlled, and international multicentre study (NCT03340922). One hundred consecutive patients with indication for PVC ablation were enrolled and randomized to AUT (n = 50) or manual (MAN, n = 50) annotation protocols using the CARTO3 navigation system. The primary endpoint was mapping success. Clinical success was defined as a PVC-burden reduction of ≥80% in the 24-h Holter within 6 months after the procedure. Mean age was 56 ± 14 years, 54% men. The mean baseline PVC burden was 25 ± 13%, and mean left ventricular ejection fraction (LVEF) 55 ± 11%. Baseline characteristics were similar between the groups. The most frequent PVC-site of origin were right ventricular outflow tract (41%), LV (25%), and left ventricular outflow tract (17%), without differences between groups. Radiofrequency (RF) time and number of RF applications were similar for both groups. Mapping and procedure times were significantly shorter in the AUT-arm (25.5 ± 14.3 vs. 32.8 ± 12.6 min, P = 0.009; and 54.8 ± 24.8 vs. 67.4 ± 25.2, P = 0.014, respectively), while more mapping points were acquired [136 (94-222) AUT vs. 79 (52-111) MAN; P < 0.001]. Mapping and clinical success were similar in both groups. There were no procedure-related complications.
Conclusion
The use of a complete automatic protocol for LAT annotation during PVC ablation procedures allows to achieve similar clinical endpoints with higher procedural efficiency when compared with conventional, manual annotation carried out by expert operators.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 12 Apr 2021; epub ahead of print
Jáuregui B, Fernández-Armenta J, Acosta J, Penela D, ... Pedrote A, Berruezo A
Europace: 12 Apr 2021; epub ahead of print | PMID: 33846728
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Abstract

Current perspectives on wearable rhythm recordings for clinical decision-making: the wEHRAbles 2 survey.

Manninger M, Zweiker D, Svennberg E, Chatzikyriakou S, ... Potpara T, Duncker D
Novel wearable devices for heart rhythm analysis using either photoplethysmography (PPG) or electrocardiogram (ECG) are in daily clinical practice. This survey aimed to assess impact of these technologies on physicians\' clinical decision-making and to define, how data from these devices should be presented and integrated into clinical practice. The online survey included 22 questions, focusing on the diagnosis of atrial fibrillation (AF) based on wearable rhythm device recordings, suitable indications for wearable rhythm devices, data presentation and processing, reimbursement, and future perspectives. A total of 539 respondents {median age 38 [interquartile range (IQR) 34-46] years, 29% female} from 51 countries world-wide completed the survey. Whilst most respondents would diagnose AF (83%), fewer would initiate oral anticoagulation therapy based on a single-lead ECG tracing. Significantly fewer still (27%) would make the diagnosis based on PPG-based tracing. Wearable ECG technology is acceptable for the majority of respondents for screening, diagnostics, monitoring, and follow-up of arrhythmia patients, while respondents were more reluctant to use PPG technology for these indications. Most respondents (74%) would advocate systematic screening for AF using wearable rhythm devices, starting at patients\' median age of 60 (IQR 50-65) years. Thirty-six percent of respondents stated that there is no reimbursement for diagnostics involving wearable rhythm devices in their countries. Most respondents (56.4%) believe that costs of wearable rhythm devices should be shared between patients and insurances. Wearable single- or multiple-lead ECG technology is accepted for multiple indications in current clinical practice and triggers AF diagnosis and treatment. The unmet needs that call for action are reimbursement plans and integration of wearable rhythm device data into patient\'s files and hospital information systems.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 10 Apr 2021; epub ahead of print
Manninger M, Zweiker D, Svennberg E, Chatzikyriakou S, ... Potpara T, Duncker D
Europace: 10 Apr 2021; epub ahead of print | PMID: 33842972
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Abstract

Risk factor management and atrial fibrillation.

Hendriks JM, Gallagher C, Middeldorp ME, Lau DH, Sanders P
The management of atrial fibrillation (AF) is multifaceted and treatment paradigms have changed significantly in the last century. The treatment of AF requires a comprehensive approach which goes beyond the treatment of the arrhythmia alone. Risk factor management has been introduced as a crucial pillar of AF management. As a result, the landscape of care delivery is changing as well, and novel models of comprehensive care delivery for AF have been introduced. This article reviews the evidence for the role of risk factor management in AF, how this can be integrated and implemented in clinical practice by applying novel models of care delivery, and finally identifies areas for ongoing research and potential healthcare reform to comprehensively manage the burgeoning AF population.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 09 Apr 2021; 23:ii52-ii60
Hendriks JM, Gallagher C, Middeldorp ME, Lau DH, Sanders P
Europace: 09 Apr 2021; 23:ii52-ii60 | PMID: 33837759
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Abstract

The bidirectional interaction between atrial fibrillation and heart failure: consequences for the management of both diseases.

Verhaert DVM, Brunner-La Rocca HP, van Veldhuisen DJ, Vernooy K
Atrial fibrillation (AF) and heart failure (HF) are both highly prevalent diseases and are accompanied by a significant disease burden and increased mortality. Although the conditions may exist independently, they often go hand in hand as each is able to provoke, sustain, and aggravate the other. In addition, the diseases share a risk profile with several coinciding cardiovascular risk factors, promoting the odds of developing both AF and HF separately from each other. When the diseases coexist, this provides additional challenges but also opportunities for the optimal treatment. The recommended management of the comorbidities has been much debated in the past decades. In this review, we describe the pathophysiological coherence of AF and HF, illustrate the current knowledge on the management of them as comorbidities of each other and look forward to future developments in this field.

The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 09 Apr 2021; 23:ii40-ii45
Verhaert DVM, Brunner-La Rocca HP, van Veldhuisen DJ, Vernooy K
Europace: 09 Apr 2021; 23:ii40-ii45 | PMID: 33837758
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Abstract

Innovations and paradigm shifts in atrial fibrillation ablation.

Mulder BA, Luermans JGLM, Hindricks G, Blaauw Y
Treatment of symptomatic atrial fibrillation has seen important changes in the past decades. Advancements have especially been made in the field of non-pharmacological treatment of this disease. Patients in whom a rhythm control strategy is chosen the place of catheter ablation has become more frontline therapy in the past years. The procedure itself has also seen changes in technologies that can be used, either using point-by-point radiofrequency or one of the single-shot techniques. One of the major limitations that remain is that re-do procedures are often necessary due to incomplete pulmonary vein isolation and/or atrial fibrillation being initiated by other mechanisms than pulmonary vein triggers. Therefore, there is further need for developing ablation tools that reproducibly isolate the pulmonary vein transmurally. Furthermore, addressing the underlying conditions before and after catheter ablation has been shown to be of great importance. In this review, we will give an overview of the evolution of catheter ablation, highlight the latest technologies and their future endeavours, and lifestyle modifications are being discussed as part of the catheter ablation strategy.

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Europace: 09 Apr 2021; 23:ii23-ii27
Mulder BA, Luermans JGLM, Hindricks G, Blaauw Y
Europace: 09 Apr 2021; 23:ii23-ii27 | PMID: 33837757
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Abstract

The RACE to the EAST. In pursuit of rhythm control therapy for atrial fibrillation-a dedication to Harry Crijns.

Reissmann B, Breithardt G, Camm AJ, Van Gelder IC, Metzner A, Kirchhof P
The RACE trial was one of the first landmark trials to establish whether restoring and maintaining sinus rhythm could reduce morbidity and mortality in patients with atrial fibrillation (AF). Its neutral outcome shaped clinical decision-making for almost 20 years. However, there were two important treatment-related factors associated with mortality of rhythm control therapy at that time: One was safety of antiarrhythmic drug therapy, and the other one withdrawal of anticoagulation after restoration of sinus rhythm. Both concerns have been overcome, and, moreover, important knowledge considering the importance of time for the treatment of AF has been gained. These insights led to the concept of the EAST-AFNET 4 trial, and after more than two decades in the pursuit of ongoing therapeutic improvement, early rhythm control therapy has demonstrated to reduce a composite of cardiovascular death, stroke, and hospitalization for worsening of HF or acute coronary syndrome, by 21% (first primary outcome, absolute reduction 1.1 per 100 patient-years). For this entire period, Harry Crijns characterized the treatment of AF patients, and contributed decisively to realizing the benefit of rhythm control therapy. It is almost easier to list the clinical trials without Harry\'s involvement than to list those which he co-designed and led.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 09 Apr 2021; 23:ii34-ii39
Reissmann B, Breithardt G, Camm AJ, Van Gelder IC, Metzner A, Kirchhof P
Europace: 09 Apr 2021; 23:ii34-ii39 | PMID: 33837756
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Abstract

A hybrid approach to complex arrhythmias.

Maesen B, Luermans JGLM, Bidar E, Chaldoupi SM, ... Pison L, Meir M
Despite many years of research, the different aspects of the mechanism of atrial fibrillation (AF) are still incompletely understood. And although the latest guidelines recommend catheter ablation with pulmonary vein isolation as a rhythm control strategy, long-term results in persistent and long-standing persistent AF are suboptimal. Historically, a mechanistic-based patient-tailored approach for the treatment of AF was impossible because of the lack real-time mapping techniques and advanced ablation tools. Therefore, surgeons created lesion sets based upon the anatomy of both atria and the safety of the incisions made by the knife. These complex open-heart procedures had to be performed through a sternotomy on the arrested heart and where therefore not generally adopted. The use of controlled energy sources such as cryothermy and radiofrequency where the first step to make the creation of these lesions less complex. With the development and improvement of electrophysiology techniques and catheters, this invasive and solely anatomical approach could again be partially redesigned. Now less invasive, it prepared the way for collaboration between electrophysiologists working on the endocardial side of the heart and cardiac surgeons providing epicardial access. The introduction of video-assisted technology and hybrid procedures has further increased the possibilities of new successful therapies. Now more than 40 years since the beginning of this exciting maze of AF procedures and still working towards a less aggressive and more comprehensive approach we give an overview of the history of the different minimally invasive surgical solutions and of the hybrid approach.

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Europace: 09 Apr 2021; 23:ii28-ii33
Maesen B, Luermans JGLM, Bidar E, Chaldoupi SM, ... Pison L, Meir M
Europace: 09 Apr 2021; 23:ii28-ii33 | PMID: 33837755
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Abstract

Role of genetics in atrial fibrillation management.

Rienstra M, Siland JE, Ellinor PT
Atrial fibrillation (AF) management has significantly improved during the career of professor Crijns. Research was implemented into guidelines and clinical practice. However, despite advances in AF management, large differences between individual treatment responses still exist and the mechanisms underlying initiation and perpetuation of AF are not completely understood. International collaborations have revealed the genetic contribution to AF and steps towards improving AF management are being made. In this short review, the most important paradigms shifts in the field of AF genetics are recognized and the future role of genetics in personalized management of AF is discussed.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 09 Apr 2021; 23:ii4-ii8
Rienstra M, Siland JE, Ellinor PT
Europace: 09 Apr 2021; 23:ii4-ii8 | PMID: 33837754
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Abstract

Antiarrhythmic drugs for atrial fibrillation: lessons from the past and opportunities for the future.

Heijman J, Hohnloser SH, Camm AJ
Atrial fibrillation (AF) remains a highly prevalent and troublesome cardiac arrhythmia, associated with substantial morbidity and mortality. Restoration and maintenance of sinus rhythm (rhythm-control therapy) is an important element of AF management in symptomatic patients. Despite significant advances and increasing importance of catheter ablation, antiarrhythmic drugs (AADs) remain a cornerstone of rhythm-control therapy. During the past 50 years, experimental and clinical research has greatly increased our understanding of AADs. As part of the special issue on paradigm shifts in AF, this review summarizes important milestones in AAD research that have shaped their current role in AF management, including (i) awareness of the proarrhythmic potential of AADs; (ii) increasing understanding of the pleiotropic effects of AADs; (iii) the development of dronedarone; and (iv) the search for AF-specific AADs. Finally, we discuss short- and long-term opportunities for better AF management through advances in AAD therapy, including personalization of AAD therapy based on individual AF mechanisms.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 09 Apr 2021; 23:ii14-ii22
Heijman J, Hohnloser SH, Camm AJ
Europace: 09 Apr 2021; 23:ii14-ii22 | PMID: 33837753
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Abstract

Early atrial fibrillation detection and the transition to comprehensive management.

Linz D, Hermans A, Tieleman RG
Current atrial fibrillation (AF) guidelines recommend screening for AF in individuals above 65 years or with other characteristics suggestive of increased stroke risk. Several mobile health (mHealth) approaches are available to identify AF. Although most wearables or ECG machines include algorithms to detect AF, an ECG confirmation of AF is necessary to establish a suspected diagnosis of AF. Early detection of AF is important to allow early initiation of AF management, and early rhythm control therapy lowered risk of adverse cardiovascular outcomes among patients with early AF aged >75 or with a CHA2DS2-VASc score ≥2 and cardiovascular conditions in the EAST-AFNET 4 study. Strategies for early AF detection should be always linked to a comprehensive work-up infrastructure organized within an integrated care pathway to allow early initiation and guidance of AF treatment in newly detected AF patients. In this review article, we summarize strategies and mHealth approaches for early AF detection and the transition to early AF management including AF symptoms evaluation and assessment of AF progression as well as AF risk factors.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 09 Apr 2021; 23:ii46-ii51
Linz D, Hermans A, Tieleman RG
Europace: 09 Apr 2021; 23:ii46-ii51 | PMID: 33837752
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Abstract

Paradigm shifts in electrophysiological mechanisms of atrial fibrillation.

Schotten U, Lee S, Zeemering S, Waldo AL
Determining the sequence of activation is a major source of information for understanding the electrophysiological mechanism(s) of atrial fibrillation (AF). However, the complex morphology of the electrograms hampers their analysis, and has stimulated generations of electrophysiologists to develop a large variety of technologies for recording, pre-processing, and analysis of fibrillation electrograms. This variability of approaches is mirrored by a large variability in the interpretation of fibrillation electrograms and, thereby, opinions regarding the basic electrophysiological mechanism(s) of AF vary widely. Multiple wavelets, different types of re-entry including rotors, double layers, multiple focal activation patterns all have been advocated, and a comprehensive and commonly accepted paradigm for the fundamental mechanisms of AF is still lacking. Here, we summarize the Maastricht perspective and Cleveland perspective regarding AF mechanism(s). We also describe some of the key observations in mapping of AF reported over the past decades, and how they changed over the years, often as results of new techniques introduced in the experimental field of AF research.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 09 Apr 2021; 23:ii9-ii13
Schotten U, Lee S, Zeemering S, Waldo AL
Europace: 09 Apr 2021; 23:ii9-ii13 | PMID: 33837750
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Abstract

Second-generation laser balloon ablation for the treatment of atrial fibrillation assessed by continuous rhythm monitoring: the LIGHT-AF study.

Rovaris G, Ciconte G, Schiavone M, Mitacchione G, ... Forleo GB, Pappone C
Aims
Balloon-based technologies have been developed to simplify catheter ablation of atrial fibrillation (AF), to improve the clinical outcome of the procedure and to achieve durable pulmonary vein isolation (PVI). The objective of this study is to evaluate the safety and efficacy of second-generation laser balloon (LB2) ablation in the treatment of AF using a continuous cardiac rhythm monitoring strategy. Atrial tachyarrhythmias (ATas) recurrences were assessed with implantable cardiac monitors (ICMs) or devices.
Methods and results
All patients underwent LB2 ablation procedure. The primary endpoint was the first recurrence of any, >5.5 and >24 h duration ATas after the blanking period (90 days). In-hospital visits were performed at 3, 6, and 12 months. Seventy-three patients (68% male, mean age 59.8 ± 11.3) were included in the study. The average procedure, fluoroscopy, and laser ablation times were 81.5 ± 30.1, 21.5 ± 12.4, and 33.8 ± 9.7, respectively. All PVs were isolated using the LB2 with no need of touch-up using focal catheters. No major complications occurred during or after the procedures. The one-year freedom from recurrences was 66.9% (95% CI: 57.0-76.7%), 81.0% (69.5-88.5%), and 86.8% (76.1-92.9%) considering any, 5.5-h and 24-h cut-off duration, respectively. At 3, 6, and 12 months, any ATas was recorded in 22%, 32%, and 25% of patients, with a ≥5% arrhythmic burden documented in 4%, 5%, and 3%, respectively. Few patients reported AF-related symptoms (7%, 8%, and 5%).
Conclusion
LB2 ablation is a safe and effective procedure, showing a high freedom from recurrences and low arrhythmic burden as documented by a continuous rhythm monitoring strategy.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 08 Apr 2021; epub ahead of print
Rovaris G, Ciconte G, Schiavone M, Mitacchione G, ... Forleo GB, Pappone C
Europace: 08 Apr 2021; epub ahead of print | PMID: 33837418
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Abstract

Toll-like receptor 4 activation modulates pericardium-myocardium interactions in lipopolysaccharide-induced atrial arrhythmogenesis.

Lin FJ, Li SJ, Lu YY, Wu WS, ... Chen SA, Chen YJ
Aims
Inflammation plays a role in the pathogenesis of atrial fibrillation (AF). Pericarditis enhanced atrial arrhythmogenesis, but the role of the pericardium remains unclear in AF. Activation of the toll-like receptor 4 (TLR4) by binding to lipopolysaccharide (LPS) promotes cardiac electrical remodelling. In this study, we hypothesized that pericarditis may induce atrial arrhythmogenesis via pericardium-myocardium interactions by TLR4 signalling.
Methods and results
Pericarditis was induced in rabbits by injecting LPS (1-2 mg/kg) into the pericardium. Conventional microelectrodes were used to record the action potentials of left atrial (LA) posterior walls (LAPWs) and LA appendages (LAAs) with and without attached pericardium in the control or pericarditis-induced rabbits. Cytokine array was used to measure the expression levels of proinflammatory cytokines in control and LPS-treated pericardium. Compared with the controls, the LPS-treated pericardium had higher expressions of IL-1α, IL-8, and MIP-1β. Rapid atrial pacing-induced burst firing in LPS-treated LAPWs and LAAs, and in control LAPWs (but not in LAAs). The incidence of pacing-induced spontaneous activity and burst firing was increased by LPS-treated pericardium but was attenuated by the control pericardium. Moreover, burst firing induced by LPS-treated pericardium was blocked upon administration of the TLR4 inhibitor, TAK-242 (100 ng/mL), ryanodine receptor inhibitor (ryanodine, 3 μM), or calmodulin kinase II inhibitor (KN-93, 1 μM).
Conclusions
Healthy and inflamed pericardium differently modulate LPS-induced atrial arrhythmogenesis. Targeting pericardium via TLR4 signalling may be a novel therapeutic strategy for AF.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 08 Apr 2021; epub ahead of print
Lin FJ, Li SJ, Lu YY, Wu WS, ... Chen SA, Chen YJ
Europace: 08 Apr 2021; epub ahead of print | PMID: 33837408
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Abstract

Sex differences in disease progression and arrhythmic risk in patients with arrhythmogenic cardiomyopathy.

Rootwelt-Norberg C, Lie ØH, Chivulescu M, Castrini AI, ... Edvardsen T, Haugaa KH
Aims
We aimed to assess sex-specific phenotypes and disease progression, and their relation to exercise, in arrhythmogenic cardiomyopathy (AC) patients.
Methods and results
In this longitudinal cohort study, we included consecutive patients with AC from a referral centre. We performed echocardiography at baseline and repeatedly during follow-up. Patients\' exercise dose at inclusion was expressed as metabolic equivalents of task (MET)-h/week. Ventricular arrhythmia (VA) was defined as aborted cardiac arrest, sustained ventricular tachycardia, or appropriate therapy by implantable cardioverter-defibrillator. We included 190 AC patients (45% female, 51% probands, age 41 ± 17 years). Ventricular arrhythmia had occurred at inclusion or occurred during follow-up in 85 patients (33% of females vs. 55% of males, P = 0.002). Exercise doses were higher in males compared with females [25 (interquartile range, IQR 14-51) vs. 12 (IQR 7-22) MET-h/week, P < 0.001]. Male sex was a marker of proband status [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.4-5.0, P = 0.003] and a marker of VA (OR 2.6, 95% CI 1.4-5.0, P = 0.003), but not when adjusted for exercise dose and age (adjusted OR 1.8, 95% CI 0.9-3.6, P = 0.12 and 1.5, 95% CI 0.7-3.1, P = 0.30, by 5 MET-h/week increments). In all, 167 (88%) patients had ≥2 echocardiographic examinations during 6.9 (IQR 4.7-9.8) years of follow-up. We observed no sex differences in deterioration of right or left ventricular dimensions and functions.
Conclusion
Male AC patients were more often probands and had higher prevalence of VA than female patients, but not when adjusting for exercise dose. Importantly, disease progression was similar between male and female patients.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 07 Apr 2021; epub ahead of print
Rootwelt-Norberg C, Lie ØH, Chivulescu M, Castrini AI, ... Edvardsen T, Haugaa KH
Europace: 07 Apr 2021; epub ahead of print | PMID: 33829244
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Impact:
Abstract

Quality indicators for the care and outcomes of adults with atrial fibrillation.

Arbelo E, (Chair), Aktaa S, Bollmann A, ... Glotzer TV, Martins Oliveira M
Aims
To develop quality indicators (QIs) that may be used to evaluate the quality of care and outcomes for adults with atrial fibrillation (AF).
Methods and results
We followed the ESC methodology for QI development. This methodology involved (i) the identification of the domains of AF care for the diagnosis and management of AF (by a group of experts including members of the ESC Clinical Practice Guidelines Task Force for AF); (ii) the construction of candidate QIs (including a systematic review of the literature); and (iii) the selection of the final set of QIs (using a modified Delphi method). Six domains of care for the diagnosis and management of AF were identified: (i) Patient assessment (baseline and follow-up), (ii) Anticoagulation therapy, (iii) Rate control strategy, (iv) Rhythm control strategy, (v) Risk factor management, and (vi) Outcomes measures, including patient-reported outcome measures (PROMs). In total, 17 main and 17 secondary QIs, which covered all six domains of care for the diagnosis and management of AF, were selected. The outcome domain included measures on the consequences and treatment of AF, as well as PROMs.
Conclusion
This document defines six domains of AF care (patient assessment, anticoagulation, rate control, rhythm control, risk factor management, and outcomes), and provides 17 main and 17 secondary QIs for the diagnosis and management of AF. It is anticipated that implementation of these QIs will improve the quality of AF care.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:494-495
Arbelo E, (Chair), Aktaa S, Bollmann A, ... Glotzer TV, Martins Oliveira M
Europace: 05 Apr 2021; 23:494-495 | PMID: 32860039
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Impact:
Abstract

Atrial fibrillation and the risk of ischaemic strokes or intracranial haemorrhages: comparisons of the catheter ablation, medical therapy, and non-atrial fibrillation population.

Kim M, Yu HT, Kim J, Kim TH, ... Lee MH, Pak HN
Aims 
Although atrial fibrillation (AF) catheter ablation (AFCA) is an effective rhythm control strategy, there is limited data on whether ischaemic stroke (IS) or intracranial haemorrhage (ICH) decreases after AFCA compared with medical therapy or non-AF population. We explored the IS and ICH risk after AFCA or medical therapy in the AF population and matched non-AF population.
Methods and results 
We compared 1629 patients with AFCA (Yonsei AF ablation cohort), 3258 with medical therapy [Korean National Health Insurance (NHIS) database], and 3258 non-AF subjects (NHIS database) following a 1:2:2 propensity score matching. All AFCA patients underwent regular rhythm follow-ups for 51 ± 29 months. Among the AFCA group, the incidence rate ratio (IRR) of ISs was significantly higher in patients with sustained AF recurrences after the last ablation (0.87%) than in those remaining in sinus rhythm (0.24%, P = 0.017; log rank P = 0.003). The IRR of ISs was significantly higher in the medical therapy (1.09%) than AFCA (0.30%, P < 0.001, log rank P < 0.001 vs. medical therapy) or non-AF groups (0.34%, P < 0.001, log rank P < 0.001 vs. medical therapy; P = 0.673, log rank P = 0.874 vs. AFCA). The IRR of ICHs was 0.17% in the medical therapy, 0.06% in the AFCA (P = 0.023, log rank P = 0.042 vs. medical therapy), and 0.12% in the non-AF group (P = 0.226, log rank P = 0.241 vs. medical therapy; P = 0.172, log rank P = 0.193 vs. AFCA).
Conclusion 
Post-procedural AF control influences the risk of ISs. Atrial fibrillation catheter ablation significantly reduces the risk of both ISs and ICHs to the extent of the non-AF population compared to the medical therapy.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:529-538
Kim M, Yu HT, Kim J, Kim TH, ... Lee MH, Pak HN
Europace: 05 Apr 2021; 23:529-538 | PMID: 33045047
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Impact:
Abstract

Mechanism and interpretation of two-for-one response to premature atrial complexes during atrioventricular node re-entry tachycardia.

Gilge JL, Bagga S, Ahmed AS, Clark BA, ... Steinberg LA, Padanilam BJ
Aims
The response to premature atrial complexes (PACs) during tachycardia has been shown to differentiate atrioventricular nodal re-entrant tachycardia (AVNRT) from focal junctional tachycardia (JT). His refractory PAC (HrPACs) perturbing the next His (resetting with fusion) is diagnostic of AVNRT and such a late PAC fusing with the native beat cannot reset the focal source of JT. Early PAC advancing the immediate His with continuation of tachycardia suggests JT but can also occur in AVNRT due to simultaneous conduction through the AV nodal fast and slow pathways [two-for-one response (TFOR)]. The objective of this study was to evaluate the incidence and mechanism of TFOR after early premature atrial complexes (ePACs) during AVNRT and to differentiate it from the known response to ePACs during JT.
Methods and results
Typical AVNRT cases were diagnosed using standard criteria. We evaluated the responses to scanning PACs delivered during tachycardia in 100 patients undergoing AV node slow pathway modification for AVNRT. The responses to HrPACs and ePACs delivered from coronary sinus os or high right atrium were retrospectively reviewed. In 10 patients, ePACs advanced the immediate His with continuation of tachycardia. In all 10 cases, HrPACs advanced the next His, confirming AVNRT as the mechanism, and indicating a TFOR.
Conclusion
A TFOR can occur in a small number of patients during AVNRT and is therefore not diagnostic of JT. However, HrPACs always perturbed the next His in these cases, confirming the diagnosis of AVNRT and allowing for differentiation from JT.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:634-639
Gilge JL, Bagga S, Ahmed AS, Clark BA, ... Steinberg LA, Padanilam BJ
Europace: 05 Apr 2021; 23:634-639 | PMID: 33176356
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Impact:
Abstract

Anatomical-based percutaneous left stellate ganglion block in patients with drug-refractory electrical storm and structural heart disease: a single-centre case series.

Savastano S, Dusi V, Baldi E, Rordorf R, ... Oltrona Visconti L, De Ferrari GM
Aims
The adoption of percutaneous stellate ganglion blockade for the treatment of drug-refractory electrical storm (ES) has been increasingly reported; however, the time of onset of the anti-arrhythmic effects, the safety of a purely anatomical approach in conscious patients and the additional benefit of repeated procedures remain unclear.
Methods and results
This study included consecutive patients undergoing percutaneous left stellate ganglion blockade (PLSGB) in our centre for drug-refractory ES. Lidocaine, bupivacaine, or a combination of both were injected in the vicinity of the left stellate ganglion. Overall, 18 PLSGBs were performed in 11 patients (age 69 ± 13 years; 63.6% men, left ventricular ejection fraction 31.6 ± 16%). Seven patients received only one PLSGB; three underwent two procedures and one required three PLSGB and two continuous infusions to control ventricular arrhythmias (VAs). All PLSGBs were performed with an anatomical approach; lidocaine, alone, or in combination was used in 77.7% of the procedures. The median burden of VAs 1 h after each block was zero compared with five in the hour before (P < 0.001); 83% of the patients were free from VAs; the efficacy at 24 h increased with repeated blocks. The anti-arrhythmic efficacy of PLSGB was not related to anisocoria. No procedure-related complications were reported.
Conclusion
Anatomical-based PLSGB is a safe and rapidly effective treatment for refractory ES; repeated blocks provide additional benefits. Percutaneous left stellate ganglion blockade should be considered for stabilizing patients to allow further ES management.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:581-586
Savastano S, Dusi V, Baldi E, Rordorf R, ... Oltrona Visconti L, De Ferrari GM
Europace: 05 Apr 2021; 23:581-586 | PMID: 33190159
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Impact:
Abstract

Impact of access route to the left ventricle on asymptomatic periprocedural brain injury: the results of a randomized trial in patients undergoing catheter ablation of ventricular tachycardia.

Borišincová E, Peichl P, Wichterle D, Šramko M, ... Čihák R, Kautzner J
Aims
Catheter ablation of ventricular tachycardia (VT) is an effective treatment in patients with structural heart disease (SHD) and recurrent arrhythmias. However, the procedure is associated with the risk of complications, including both manifest and asymptomatic cerebral thromboembolic events. We hypothesized that periprocedural asymptomatic brain injury (ABI) can be reduced by using transseptal instead of the retrograde access route to the left ventricle (LV).
Methods and results
Consecutive patients undergoing VT ablation for SHD were randomized 1:1 to either retrograde or transseptal LV access. All patients underwent radiofrequency ablation in conscious sedation with the use of an irrigated tip catheter. The degree of brain damage was evaluated by serum level of biomarker S100B. Significant ABI was defined as a post-ablation relative increase of S100B level >30%. A total of 144 patients (66 ± 9 years; 14 females; 90% coronary artery disease; LV ejection fraction: 30 ± 8%) were enrolled and 72 were allocated to each study groups. Symptomatic neurological complication of the procedure was not observed in any subject. A significant ABI was detected in 19.4% of patients. It was more commonly observed in subjects randomized to retrograde vs. transseptal LV access (26.4% vs. 12.5%, P = 0.04). In a multivariate analysis, only retrograde LV access and advanced age were independent determinants of significant ABI.
Conclusion
Significant ABI after ablation of VT in patients with SHD can be detected in one-fifth of subjects. Retrograde access to LV is associated with a two-fold higher probability of significant ABI.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:610-615
Borišincová E, Peichl P, Wichterle D, Šramko M, ... Čihák R, Kautzner J
Europace: 05 Apr 2021; 23:610-615 | PMID: 33185243
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Impact:
Abstract

Pulmonary vein isolation alone vs. more extensive ablation with defragmentation and linear ablation of persistent atrial fibrillation: the EARNEST-PVI trial.

Inoue K, Hikoso S, Masuda M, Furukawa Y, ... Sakata Y, OCVC Arrhythmia Investigators
Aims
Previous studies could not demonstrate any benefit of more intensive ablation in addition to pulmonary vein isolation (PVI) including complex fractionated atrial electrogram (CFAE) and linear ablation for recurrence in the initial catheter ablation of persistent atrial fibrillation (AF). This study aimed to establish the non-inferiority of PVI alone to PVI plus these additional ablation strategies.
Methods and results
Patients with persistent AF who underwent an initial catheter ablation (n = 512, long-standing persistent AF; 128 cases) were randomly assigned in a 1:1 ratio to either PVI alone (PVI-alone group) or PVI plus CFAE and/or linear ablation (PVI-plus group). After excluding 15 cases who did not receive procedures, we analysed 249 and 248 patients, respectively. The primary endpoint was recurrence of AF, atrial flutter, and/or atrial tachycardia, and the non-inferior margin was set at a hazard ratio of 1.43. In the PVI-plus group, 85.1% of patients had linear ablation and 15.3% CFAE ablation. After 12 months, freedom from the primary endpoint occurred in 71.3% of patients in the PVI-alone group and in 78.3% in the PVI-plus group [hazard ratio = 1.56 (95% confidence interval: 1.10-2.24), non-inferior P = 0.3062]. The procedure-related complication rates were 2.0% in the PVI-alone group and 3.6% in the PVI-plus group (P = 0.199).
Conclusion
This randomized trial did not establish the non-inferiority of PVI alone to PVI plus linear ablation or CFAE ablation in patients with persistent AF, but implied that the PVI plus strategy was promising to improve the clinical efficacy (NCT03514693).

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:565-574
Inoue K, Hikoso S, Masuda M, Furukawa Y, ... Sakata Y, OCVC Arrhythmia Investigators
Europace: 05 Apr 2021; 23:565-574 | PMID: 33200213
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Impact:
Abstract

Risk of arrhythmias after myocardial infarction in patients with left ventricular systolic dysfunction according to mode of revascularization: a Cardiac Arrhythmias and RIsk Stratification after Myocardial infArction (CARISMA) substudy.

Thomsen AF, Jacobsen PK, Køber L, Joergensen RM, ... Jacobsen UG, Jøns C
Aims
The Cardiac Arrhythmias and RIsk Stratification after Myocardial infArction (CARISMA) study was an observational trial including 312 patients with acute myocardial infarction (MI) and left ventricular ejection fraction (LVEF) <40%. Primary percutaneous intervention (pPCI) was introduced 2 years after start of the enrolment, dividing the population into two groups: pre- and post-pPCI. This substudy sought to describe the influence of the mode of revascularization on long-term risk of new-onset atrial fibrillation (AF), bradyarrhythmia, and ventricular tachycardia and the subsequent risk of relevant major cardiovascular events (MACE).
Methods and results
The study included the 268 patients without a history of AF. All patients received an implantable cardiac monitor (ICM) and were followed for 2 years. The choice of revascularization was made by the treating team independently of the trial and retrospectively divided into pPCI, subacute PCI, primary thrombolysis, or no revascularization. Endpoints were new-onset arrhythmia and MACE.A total of 77 patients received no revascularization, whereas 49 received thrombolysis only and 142 received any PCI. The adjusted hazard ratio (HR) for developing any arrhythmia and the subsequently risk of MACE were increased in non-revascularized or thrombolysed patients compared with PCI-patients (any arrhythmia, non-revascularization: HR = 1.7, P = 0.01 and thrombolysis: HR = 1.6, P = 0.05; MACE, non-revascularization: HR = 3.1, P = 0.05 and thrombolysis: HR = 3.1, P = 0.08). All HRs were adjusted for significant baseline and clinically considered covariates and stratified for calendar year.
Conclusion
This study is the first to demonstrate that the long-term risk of arrhythmia documented by an ICM and the subsequent risk of MACE were increased in non-revascularized or thrombolysed patients compared with PCI-patients in a post-MI population with LVEF <40%.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:616-623
Thomsen AF, Jacobsen PK, Køber L, Joergensen RM, ... Jacobsen UG, Jøns C
Europace: 05 Apr 2021; 23:616-623 | PMID: 33200171
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Impact:
Abstract

Significance of post-pacing intervals shorter than tachycardia cycle length for successful catheter ablation of atypical flutter.

Dall\'Aglio PB, Johner N, Namdar M, Shah DC
Aims
During entrainment mapping of macro-reentrant tachycardias, the time difference (dPPI) between post-pacing interval (PPI) and tachycardia cycle length (TCL) is thought to be a function of the distance of the pacing site to the re-entry circuit and dPPI < 30 ms is considered within the re-entry circuit. This study assessed the importance of PPI < TCL as a successful target for atypical flutter ablation.
Methods and results
A total of 177 ablation procedures were investigated. Surface electrocardiograms (ECGs) were evaluated and combined activation and entrainment mapping were performed to choose ablation sites. Each entrainment sequence immediately preceding static radiofrequency delivery at the same site was analysed. A total of 545 entrainment sequences were analysed. dPPI < 0 ms was observed in 45.3% (247/545) sequences. Ablation resulted in tachycardia termination more often at sites with dPPI < 0 (27.8% vs. 14.5%, P < 0.001) and with a progressively increasingly inverse correlation between dPPI duration and ablation success [odds ratio (OR): 0.974; 95% confidence interval (CI) 0.960-0.988; P < 0.001]. Tachycardia termination or cycle length prolongation also occurred more often at sites with dPPI < 0 (50.6% vs. 33.2%, P < 0.001) and with a similar inverse correlation with dPPI duration (OR: 0.972; 95% CI 0.960-0.984; P < 0.001). Twelve-lead synchronous isoelectric intervals were observed in 64.4% (163/253) flutter ECGs and were associated with a dPPI < 0 (75.3% vs. 55.8%, P < 0.001).
Conclusion
When combined with activation mapping, a negative dPPI is a more effective parameter for identifying a target for successful ablation compared to a dPPI = 0-30 ms. Its occurrence is associated with a critical small narrow slow-conducting isthmus at the target site.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:624-633
Dall'Aglio PB, Johner N, Namdar M, Shah DC
Europace: 05 Apr 2021; 23:624-633 | PMID: 33197256
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Impact:
Abstract

Impact of contact force sensing technology on outcome of catheter ablation of idiopathic pre-mature ventricular contractions originating from the outflow tracts.

Reichlin T, Baldinger SH, Pruvot E, Bisch L, ... Kühne M, Sticherling C
Aims
Catheter ablation of frequent idiopathic pre-mature ventricular contractions (PVC) is increasingly performed. While potential benefits of contact force (CF)-sensing technology for atrial fibrillation ablation have been assessed in several studies, the impact of CF-sensing on ventricular arrhythmia ablation remains unknown. This study aimed to compare outcomes of idiopathic outflow tract PVC ablation when using standard ablation catheters as opposed to CF-sensing catheters.
Methods and results
In a retrospective multi-centre study, unselected patients undergoing catheter ablation of idiopathic outflow tract PVCs between 2013 and 2016 were enrolled. All procedures were performed using irrigated-tip ablation catheters and a 3D electro-anatomical mapping system. Sustained ablation success was defined as a  ≥80% reduction of pre-procedural PVC burden determined by 24 h Holter ECG during follow-up. Overall, 218 patients were enrolled (median age 52 years, 51% males). Baseline and procedural data were similar in the standard ablation (24%) and the CF-sensing group (76%). Overall, the median PVC burden decreased from 21% (IQR 10-30%) before ablation to 0.2% (IQR 0-3.0%) after a median follow-up of 2.3 months (IQR 1.4-3.9 months). The rates of both acute (91% vs. 91%, P = 0.94) and sustained success (79% vs. 74%, P = 0.44) were similar in the standard ablation and the CF-sensing groups. No differences were observed in subgroups according to arrhythmia origin from the RVOT (65%) or LVOT (35%). Complications were rare (1.8%) and evenly distributed between the two groups.
Conclusion
The use of CF-sensing technology is not associated with increased success rate nor decreased complication rate in idiopathic outflow tract PVC ablation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:603-609
Reichlin T, Baldinger SH, Pruvot E, Bisch L, ... Kühne M, Sticherling C
Europace: 05 Apr 2021; 23:603-609 | PMID: 33207371
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Impact:
Abstract

Incidence, epidemiology, diagnosis and prognosis of atrio-oesophageal fistula following percutaneous catheter ablation: a French nationwide survey.

Gandjbakhch E, Mandel F, Dagher Y, Hidden-Lucet F, Rollin A, Maury P
Aims
Rate, incidence, risk factors, and optimal management of atrio-oesophageal fistula (AOF) after catheter ablation for atrial fibrillation (AF) remain obscure.
Methods and results
All French centres performing AF ablation were identified and surveys were sent concerning the number of procedures, eventual cases of AOF, and characteristics of such cases. Eighty-two of the 103 centres (80%) performing AF ablation in France were included, with a total of 129 286 AF ablations since 2006 (93% of the whole procedures in France). Thirty-three AOF were reported (reported rate 0.026% per procedure) with a stable reported annual incidence despite the increasing number of procedures. Sensitivity of computed tomography (CT) scan for AOF was 81%. Mortality was 60%, significantly lower in case of surgical corrective therapy (31 vs. 93%, P = 0.001).
Conclusion
The reported rate of AOF after AF ablation in this nationwide survey was 0.026%, with a stable reported annual incidence over time. A normal CT scan does not rule out the diagnosis and should be repeated in case of suspicion. Prognosis remains poor with a mortality of 60% and crucially dependant of immediate surgical correction. No clear protective strategy has been proven effective.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:557-564
Gandjbakhch E, Mandel F, Dagher Y, Hidden-Lucet F, Rollin A, Maury P
Europace: 05 Apr 2021; 23:557-564 | PMID: 33221901
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Impact:
Abstract

Effect of alcohol consumption on the risk of adverse events in atrial fibrillation: from the COmparison study of Drugs for symptom control and complication prEvention of Atrial Fibrillation (CODE-AF) registry.

Lim C, Kim TH, Yu HT, Lee SR, ... Lee YS, Joung B
Aims
The aim of this study is to determine the relationship between alcohol consumption and atrial fibrillation (AF)-related adverse events in the AF population.
Methods and results
A total of 9411 patients with nonvalvular AF in a prospective observational registry were categorized into four groups according to the amount of alcohol consumption-abstainer-rare, light (<100 g/week), moderate (100-200 g/week), and heavy (≥200 g/week). Data on adverse events (ischaemic stroke, transient ischaemic attack, systemic embolic event, or AF hospitalization including for AF rate or rhythm control and heart failure management) were collected for 17.4 ± 7.3 months. A Cox proportional hazard models was performed to calculate hazard ratios (HRs), and propensity score matching was conducted to validate the results. The heavy alcohol consumption group showed an increased risk of composite adverse outcomes [adjusted hazard ratio (aHR) 1.32, 95% confidence interval (CI) 1.06-1.66] compared with the reference group (abstainer-rare group). However, no significant increased risk for adverse outcomes was observed in the light (aHR 0.88, 95% CI 0.68-1.13) and moderate (aHR 0.91, 95% CI 0.63-1.33) groups. In subgroup analyses, adverse effect of heavy alcohol consumption was significant, especially among patients with low CHA2DS2-VASc score, without hypertension, and in whom β-blocker were not prescribed.
Conclusion
Our findings suggest that heavy alcohol consumption increases the risk of adverse events in patients with AF, whereas light or moderate alcohol consumption does not.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:548-556
Lim C, Kim TH, Yu HT, Lee SR, ... Lee YS, Joung B
Europace: 05 Apr 2021; 23:548-556 | PMID: 33227134
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Impact:
Abstract

Reconstruction of three-dimensional biventricular activation based on the 12-lead electrocardiogram via patient-specific modelling.

Pezzuto S, Prinzen FW, Potse M, Maffessanti F, ... Krause R, Auricchio A
Aims
Non-invasive imaging of electrical activation requires high-density body surface potential mapping. The nine electrodes of the 12-lead electrocardiogram (ECG) are insufficient for a reliable reconstruction with standard inverse methods. Patient-specific modelling may offer an alternative route to physiologically constraint the reconstruction. The aim of the study was to assess the feasibility of reconstructing the fully 3D electrical activation map of the ventricles from the 12-lead ECG and cardiovascular magnetic resonance (CMR).
Methods and results
Ventricular activation was estimated by iteratively optimizing the parameters (conduction velocity and sites of earliest activation) of a patient-specific model to fit the simulated to the recorded ECG. Chest and cardiac anatomy of 11 patients (QRS duration 126-180 ms, documented scar in two) were segmented from CMR images. Scar presence was assessed by magnetic resonance (MR) contrast enhancement. Activation sequences were modelled with a physiologically based propagation model and ECGs with lead field theory. Validation was performed by comparing reconstructed activation maps with those acquired by invasive electroanatomical mapping of coronary sinus/veins (CS) and right ventricular (RV) and left ventricular (LV) endocardium. The QRS complex was correctly reproduced by the model (Pearson\'s correlation r = 0.923). Reconstructions accurately located the earliest and latest activated LV regions (median barycentre distance 8.2 mm, IQR 8.8 mm). Correlation of simulated with recorded activation time was very good at LV endocardium (r = 0.83) and good at CS (r = 0.68) and RV endocardium (r = 0.58).
Conclusion
Non-invasive assessment of biventricular 3D activation using the 12-lead ECG and MR imaging is feasible. Potential applications include patient-specific modelling and pre-/per-procedural evaluation of ventricular activation.

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 05 Apr 2021; 23:640-647
Pezzuto S, Prinzen FW, Potse M, Maffessanti F, ... Krause R, Auricchio A
Europace: 05 Apr 2021; 23:640-647 | PMID: 33241411
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Impact:
Abstract

The evolution of cardiac resynchronization therapy and an introduction to conduction system pacing: a conceptual review.

Herweg B, Welter-Frost A, Vijayaraman P
In chronic systolic heart failure and conduction system disease, cardiac resynchronization therapy (CRT) is the only known non-pharmacologic heart failure therapy that improves cardiac function, functional capacity, and survival while decreasing cardiac workload and hospitalization rates. While conventional bi-ventricular pacing has been shown to benefit patients with heart failure and conduction system disease, there are limitations to its therapeutic success, resulting in widely variable clinical response. Limitations of conventional CRT evolve around myocardial scar, fibrosis, and inability to effectively simulate diseased tissue. Studies have shown endocardial stimulation in closer proximity to the specialized conduction system is more effective when compared with epicardial stimulation. Several observational and acute haemodynamic studies have demonstrated improved electrical resynchronization and echocardiographic response with conduction system pacing (CSP). Our objective is to provide a systematic review of the evolution of CRT, and an introduction to CSP as an intriguing, though experimental physiologic alternative to conventional CRT.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:496-510
Herweg B, Welter-Frost A, Vijayaraman P
Europace: 05 Apr 2021; 23:496-510 | PMID: 33247913
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Impact:
Abstract

Prediction of low-voltage areas using modified APPLE score.

Seewöster T, Kosich F, Sommer P, Bertagnolli L, Hindricks G, Kornej J
Aims
The presence of low-voltage areas (LVAs) in patients with atrial fibrillation (AF) reflects left atrial (LA) electroanatomical substrate, which is essential for individualized AF management. However, echocardiographic anteroposterior LA diameter included into previous LVAs prediction scores does not mirror LA size accurately and impaired left ventricular ejection fraction (LV-EF) is not directly associated with atrial myopathy. Therefore, we aimed to compare a modified (m)APPLE score, which included LA volume (LAV) and LA emptying fraction (LA-EF) with the regular APPLE score for the prediction of LVAs.
Methods and results
In patients undergoing first AF catheter ablation, LVAs were determined peri-interventionally using high-density maps and defined as signal amplitude <0.5 mV. All patients underwent cardiovascular magnetic resonance imaging before intervention. The APPLE (one point for Age ≥ 65 years, Persistent AF, imPaired eGFR ≤ 60 mL/min/1.73 m2, LA diameter ≥ 43 mm, and LVEF < 50%) and (m)APPLE (last two variables changed by LAV ≥ 39 mL/m2, and LA-EF < 31%) scores were calculated at baseline. The study population included 219 patients [median age 65 (interquartile range 57-72) years, 41% females, 59% persistent AF, 25% LVAs]. Both scores were significantly associated with LVAs [OR 1.817, 95% CI 1.376-2.399 for APPLE and 2.288, 95% CI 1.650-3.172 for (m)APPLE]. Using receiver operating characteristic curves analysis, the (m)APPLE score [area under the curve (AUC) 0.779, 95% CI 0.702-0.855] showed better LVAs prediction than the APPLE score (AUC 0.704, 95% CI 0.623-0.784), however, without statistically significant difference (P = 0.233).
Conclusion
The modified (m)APPLE score demonstrated good prognostic value for LVAs prediction and was comparable with the regular APPLE score.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:575-580
Seewöster T, Kosich F, Sommer P, Bertagnolli L, Hindricks G, Kornej J
Europace: 05 Apr 2021; 23:575-580 | PMID: 33279992
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Impact:
Abstract

Radiofrequency ablation: technological trends, challenges, and opportunities.

Habibi M, Berger RD, Calkins H
More than three decades have passed since utilization of radiofrequency (RF) ablation in the treatment of cardiac arrhythmias. Although several limitations and challenges still exist, with improvements in catheter designs and delivery of energy the way we do RF ablation now is much safer and more efficient. This review article aims to give an overview on historical advances on RF ablation and challenges in performing safe and efficient ablation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:511-519
Habibi M, Berger RD, Calkins H
Europace: 05 Apr 2021; 23:511-519 | PMID: 33253390
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Impact:
Abstract

Prevalence and prognostic association of ventricular arrhythmia in non-ischaemic heart failure patients: results from the DANISH trial.

Boas R, Thune JJ, Pehrson S, Køber L, ... Svendsen JH, Dixen U
Aims
Improved risk stratification to identify non-ischaemic heart failure patients who will benefit from primary prophylactic implantable cardioverter-defibrillator (ICD) is needed. We examined the potential of ventricular arrhythmia to identify patients who could benefit from an ICD.
Methods and results
A total of 850 non-ischaemic systolic heart failure patients with left ventricle ≤35% and elevated N-terminal pro-brain natriuretic peptides had a 24-h Holter monitor recording performed. We examined present non-sustained ventricular tachycardia (NSVT), defined as ≥3 consecutive premature ventricular contractions (PVCs) with a rate of ≥100/min, and number of PVCs per hour stratified into low (<30) and high burden (≥30) groups. Outcome measures were overall mortality, sudden cardiac death (SCD), and cardiovascular death (CVD). In total, 193 patients died, 49 from SCD and 125 from CVD. Non-sustained ventricular tachycardia (365 patients) was significantly associated with increased all-cause mortality [hazard ratio (HR) 1.47; 95% confidence interval (CI) 1.07-2.03; P = 0.02] and to CVD (HR 1.89; CI 1.25-2.87; P = 0.003). High burden PVC (352 patients) was associated with increased all-cause mortality (HR1.38; CI 1.00-1.90; P = 0.046) and with CVD (HR 1.78; CI 1.19-2.66; P = 0.005). There was no statistically significant association with SCD for neither NSVT nor PVC. In interaction analyses, neither NSVT (P = 0.56) nor high burden of PVC (P = 0.97) was associated with survival benefit from ICD implantation.
Conclusion
Ventricular arrhythmia in non-ischaemic heart failure patients was associated with a worse prognosis but could not be used to stratify patients to ICD implantation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:587-595
Boas R, Thune JJ, Pehrson S, Køber L, ... Svendsen JH, Dixen U
Europace: 05 Apr 2021; 23:587-595 | PMID: 33257933
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Impact:
Abstract

SETAP: epidemiology and prevention of stroke and transient ischaemic attack in Czech patients with atrial fibrillation.

Táborský M, Dušek L, Kautzner J, Vícha M, ... Bezděková M, Skála T
Aims
The aim of this study is to analyse the prevalence, epidemiology, and anticoagulation prevention of stroke or transient ischaemic attack (TIA) in Czech patients with atrial fibrillation (AF).
Methods and results
Retrospective observational analysis of diagnoses, procedures, and treatment reported to the Czech National Registry of Reimbursed Healthcare Services between 2015 and 2018. Prevalence of AF in 2018 was 4.3% of Czech population and the prevalence of stroke/TIA in AF patients was 22.3% with annual incidence of 181.62 cases per 100 000 inhabitants. In 2018, CHA2DS2-ASc score ≥4 was present in 98% AF patients in secondary and 59% in primary prevention, respectively, while the anticoagulation treatment was used by 71-81% of them. Between 2015 and 2018, the percentage of AF patients treated with warfarin monotherapy in primary prevention decreased from 35% to 31%, with acetylsalicylic acid (ASA) monotherapy from 18% to 16% and non-vitamin K antagonist oral anticoagulants (NOACs) monotherapy increased from 7% to 11%. In secondary prevention, the percentage of warfarin monotherapy treatment decreased from 35% to 32%, with ASA monotherapy from 20% to 18% and with NOACs monotherapy increased from 9% to 15%.
Conclusion
This study followed all Czech patients with AF. The unadjusted prevalence and incidence of AF was higher compared with other countries and 2019 European Society of Cardiology Statistics. The study identified several gaps in standard of reimbursed care. 20-30% of AF patients with other risk factors were without any prevention medication and the share of ASA monotherapy in treated patients was 16-18%.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:539-547
Táborský M, Dušek L, Kautzner J, Vícha M, ... Bezděková M, Skála T
Europace: 05 Apr 2021; 23:539-547 | PMID: 33305813
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Impact:
Abstract

Catheter ablation of atrial fibrillation: cardiac imaging guidance as an adjunct to the electrophysiological guided approach.

Markman TM, Khoshknab M, Nazarian S
Catheter ablation is increasingly utilized to treat patients with atrial fibrillation (AF). Despite progress in technology and procedural strategy, there remain significant limitations with suboptimal outcomes. The role of imaging has continued to evolve, and multimodality imaging now presents an important opportunity to make substantial progress in the safety and efficacy of ablation. In this review, we discuss the history of imaging in the ablation of AF with a specific focus on the ability of cardiac computed tomography and magnetic resonance imaging to characterize anatomy, arrhythmogenic substrate, and guide ablation strategy. We will review the progress that has been made and highlight many of the limitations as well as future directions for the field.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 05 Apr 2021; 23:520-528
Markman TM, Khoshknab M, Nazarian S
Europace: 05 Apr 2021; 23:520-528 | PMID: 33555014
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Impact:
Abstract

Similar outcomes with manual contact force ablation catheters and traditional catheters in the treatment of outflow tract premature ventricular complexes.

Ábrahám P, Ambrus M, Herczeg S, Szegedi N, ... Merkely B, Gellér L
Aims
Unlike in atrial fibrillation ablation, there is a lack of appropriately sized and properly designed studies regarding outflow tract (OT) premature ventricular complex (PVC) ablation outcomes with contact force sensing (CFS) catheters. We aimed to compare the acute success-, complication-, and long-term recurrence rates of manual CFS catheters with traditional irrigated catheters (T) in OT PVC ablation.
Methods and results
Single-centre, propensity-matched data of 75-75 patients ablated for right-sided OT (RVOT) or left-sided OT (LVOT) PVCs in 2015-17 with CFS or T catheters were compared. Acute success rate, peri-procedural complications, post-procedural daily PVC burden, and long-term recurrence rates were compared on intention-to-treat basis. Acute success rate equalled 80% in both groups, with no difference in force values in the CFS group comparing successful or failed cases [12.0 (8.75-17.0) vs. 16.0 (10.25-22.25) g, P = 0.21]. There were three cases of pseudo-aneurysm and one cardiac tamponade. PVC burden fell significantly from baseline 22 (15-30)% to 2 (0-10)% (P < 0.0001), with no difference between catheter types [CFS: 1 (0-7)% vs. T: 4 (1-12) %; P = 0.21]. There was no significant difference in recurrence-free survival of CFS and T catheters (58 vs. 59%, P = 0.29) during 12 months of follow-up, respectively. Recurrence in the CFS group did not differ either by the force exerted below or above the median value of 12 g (P = 0.66).
Conclusion
Both types of catheters can effectively reduce OT PVC burden with minimal serious complication rates. Ablation with CFS or T catheters gives similar acute- and long-term results.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 05 Apr 2021; 23:596-602
Ábrahám P, Ambrus M, Herczeg S, Szegedi N, ... Merkely B, Gellér L
Europace: 05 Apr 2021; 23:596-602 | PMID: 33576378
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Impact:
Abstract

Left femoral venous access for leadless pacemaker implantation: patient characteristics and outcomes.

Jelisejevas J, Breitenstein A, Hofer D, Winnik S, Steffel J, Saguner AM
Aims
Leadless pacing has become an alternative approach for patients requiring a single-chamber pacemaker. Conventionally, leadless Micra Transcatheter Pacing System (TPS) pacemakers are implanted via a right femoral venous access. However, due to various reasons, a left-sided femoral venous approach may be necessary. We hypothesized that a left-sided femoral venous approach is as safe and effective when compared with a right-sided approach. We assessed indications, procedural characteristics, safety and mid-term outcomes of Micra TPS implantation via a left femoral venous approach when compared with the conventional right-sided approach.
Methods and results
In this retrospective single-centre analysis, 143 consecutive patients undergoing Micra TPS implantation were included. 87% (125/143) underwent Micra TPS implantation via a right, and 13% (18/143) via a left femoral venous access. The mean age at implantation was 79.8 ± 7.5 years. Acute procedural success, mean procedure and fluoroscopy times as well as device parameters at implantation and follow-up (mean 15 ± 11.5 months) were similar between the two groups. Five major complications (3.5%) were encountered, all using a right-sided approach. After a transfemoral TAVI procedure, left femoral venous access was used in 42% of cases when compared with 8% in the remaining population (P = 0.003).
Conclusions
A left femoral venous access for Micra TPS implantation is safe and effective with an excellent implantation success rate similar to a conventional right femoral venous access without longer implantation and fluoroscopy times. The most frequent reason for choosing left vs. right femoral venous access was a previous transfemoral TAVI procedure.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 04 Apr 2021; epub ahead of print
Jelisejevas J, Breitenstein A, Hofer D, Winnik S, Steffel J, Saguner AM
Europace: 04 Apr 2021; epub ahead of print | PMID: 33822918
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Impact:
Abstract

Endovascular occlusion balloon-related thrombosis during transvenous lead extraction.

Pothineni NVK, Tschabrunn CM, Carrillo R, Schaller RD
Aims
The aim of this study is to evaluate the incidence, predictors, and outcomes of balloon-related thrombosis (BRT) in patients undergoing transvenous lead extraction (TLE). Use of an endovascular occlusion balloon has improved outcomes of superior vena cava injuries during TLE. Its thrombogenicity in clinical practice is unknown.
Methods and results
We prospectively evaluated consecutive patients undergoing prophylactic balloon placement during TLE utilizing two procedural workflows: one with the balloon within the inferior vena cava during the entire case (standard cohort) and one limiting the balloon\'s dwell time (abbreviated cohort). Intracardiac echocardiography was used to evaluate for significant BRT (thrombus > 1 cm) after TLE. Forty-two patients (21 in each group) were included. Age, left ventricular ejection fraction, procedural indication, number of leads, and lead dwell time were similar between the groups. Balloon dwell time was significantly longer in the standard group (128 ± 74 vs. 25 ± 18 min, P < 0.001) as was BRT (14/21 vs. 1/21, P < 0.001). Mean thrombus length and width in the standard group was 3.99 ± 1.40 and 0.45 ± 0.16 cm, respectively and 5.2 × 0.4 cm in one patient in the abbreviated group. Between patients with and without BRT in the standard group, balloon dwell times were similar (113 ± 64 vs. 156 ± 88 min, P = 0.21). One patient in the standard group had a pulmonary embolism on post-operative Day 3 and was initiated on oral anticoagulation.
Conclusion
Prophylactic balloon placement for the entirety of the case is associated with a high incidence of BRT; a finding that is decreased when an abbreviated workflow is utilized.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 04 Apr 2021; epub ahead of print
Pothineni NVK, Tschabrunn CM, Carrillo R, Schaller RD
Europace: 04 Apr 2021; epub ahead of print | PMID: 33822905
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Impact:
Abstract

The European TeleCheck-AF project on remote app-based management of atrial fibrillation during the COVID-19 pandemic: centre and patient experiences.

Gawałko M, Duncker D, Manninger M, van der Velden RMJ, ... Hendriks JM, Linz D
Aims
TeleCheck-AF is a multicentre international project initiated to maintain care delivery for patients with atrial fibrillation (AF) during COVID-19 through teleconsultations supported by an on-demand photoplethysmography-based heart rate and rhythm monitoring app (FibriCheck®). We describe the characteristics, inclusion rates, and experiences from participating centres according the TeleCheck-AF infrastructure as well as characteristics and experiences from recruited patients.
Methods and results
Three surveys exploring centre characteristics (n = 25), centre experiences (n = 23), and patient experiences (n = 826) were completed. Self-reported patient characteristics were obtained from the app. Most centres were academic (64%) and specialized public cardiology/district hospitals (36%). Majority of the centres had AF outpatient clinics (64%) and only 36% had AF ablation clinics. The time required to start patient inclusion and total number of included patients in the project was comparable for centres experienced (56%) or inexperienced in mHealth use. Within 28 weeks, 1930 AF patients were recruited, mainly for remote AF control (31% of patients) and AF ablation follow-up (42%). Average inclusion rate was highest during the lockdown restrictions and reached a steady state at a lower level after easing the restrictions (188 vs. 52 weekly recruited patients). Majority (>80%) of the centres reported no problems during the implementation of the TeleCheck-AF approach. Recruited patients [median age 64 (55-71), 62% male] agreed that the FibriCheck® app was easy to use (94%).
Conclusion
Despite different health care settings and mobile health experiences, the TeleCheck-AF approach could be set up within an extremely short time and easily used in different European centres during COVID-19.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 01 Apr 2021; epub ahead of print
Gawałko M, Duncker D, Manninger M, van der Velden RMJ, ... Hendriks JM, Linz D
Europace: 01 Apr 2021; epub ahead of print | PMID: 33822029
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Impact:
Abstract

CarDiac magnEtic Resonance for prophylactic Implantable-cardioVerter defibrillAtor ThErapy in Non-Ischaemic dilated CardioMyopathy: an international Registry.

Guaricci AI, Masci PG, Muscogiuri G, Guglielmo M, ... Schwitter J, Pontone G
Aims
The aim of this registry was to evaluate the additional prognostic value of a composite cardiac magnetic resonance (CMR)-based risk score over standard-of-care (SOC) evaluation in a large cohort of consecutive unselected non-ischaemic cardiomyopathy (NICM) patients.
Methods and results
In the DERIVATE registry (www.clinicaltrials.gov/registration: RCT#NCT03352648), 1000 (derivation cohort) and 508 (validation cohort) NICM patients with chronic heart failure (HF) and left ventricular ejection fraction <50% were included. All-cause mortality and major adverse arrhythmic cardiac events (MAACE) were the primary and secondary endpoints, respectively. During a median follow-up of 959 days, all-cause mortality and MAACE occurred in 72 (7%) and 93 (9%) patients, respectively. Age and >3 segments with midwall fibrosis on late gadolinium enhancement (LGE) were the only independent predictors of all-cause mortality (HR: 1.036, 95% CI: 1.0117-1.056, P < 0.001 and HR: 2.077, 95% CI: 1.211-3.562, P = 0.008, respectively). For MAACE, the independent predictors were male gender, left ventricular end-diastolic volume index by CMR (CMR-LVEDVi), and >3 segments with midwall fibrosis on LGE (HR: 2.131, 95% CI: 1.231-3.690, P = 0.007; HR: 3.161, 95% CI: 1.750-5.709, P < 0.001; and HR: 1.693, 95% CI: 1.084-2.644, P = 0.021, respectively). A composite clinical and CMR-based risk score provided a net reclassification improvement of 63.7% (P < 0.001) for MAACE occurrence when added to the model based on SOC evaluation. These findings were confirmed in the validation cohort.
Conclusion
In a large multicentre, multivendor cohort registry reflecting daily clinical practice in NICM work-up, a composite clinical and CMR-based risk score provides incremental prognostic value beyond SOC evaluation, which may have impact on the indication of implantable cardioverter-defibrillator implantation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 31 Mar 2021; epub ahead of print
Guaricci AI, Masci PG, Muscogiuri G, Guglielmo M, ... Schwitter J, Pontone G
Europace: 31 Mar 2021; epub ahead of print | PMID: 33792661
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Impact:
Abstract

Smartphone electrocardiogram for detecting atrial fibrillation after a cerebral ischaemic event: a multicentre randomized controlled trial.

Koh KT, Law WC, Zaw WM, Foo DHP, ... Fong AYY, Ong TK
Aims
Atrial fibrillation (AF) is a preventable cause of ischaemic stroke but it is often undiagnosed and undertreated. The utility of smartphone electrocardiogram (ECG) for the detection of AF after ischaemic stroke is unknown. The aim of this study is to determine the diagnostic yield of 30-day smartphone ECG recording compared with 24-h Holter monitoring for detecting AF ≥30 s.
Methods and results
In this multicentre, open-label study, we randomly assigned 203 participants to undergo one additional 24-h Holter monitoring (control group, n = 98) vs. 30-day smartphone ECG monitoring (intervention group, n = 105) using KardiaMobile (AliveCor®, Mountain View, CA, USA). Major inclusion criteria included age ≥55 years old, without known AF, and ischaemic stroke or transient ischaemic attack (TIA) within the preceding 12 months. Baseline characteristics were similar between the two groups. The index event was ischaemic stroke in 88.5% in the intervention group and 88.8% in the control group (P = 0.852). AF lasting ≥30 s was detected in 10 of 105 patients in the intervention group and 2 of 98 patients in the control group (9.5% vs. 2.0%; absolute difference 7.5%; P = 0.024). The number needed to screen to detect one AF was 13. After the 30-day smartphone monitoring, there was a significantly higher proportion of patients on oral anticoagulation therapy at 3 months compared with baseline in the intervention group (9.5% vs. 0%, P = 0.002).
Conclusions
Among patients ≥55 years of age with a recent cryptogenic stroke or TIA, 30-day smartphone ECG recording significantly improved the detection of AF when compared with the standard repeat 24-h Holter monitoring.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 29 Mar 2021; epub ahead of print
Koh KT, Law WC, Zaw WM, Foo DHP, ... Fong AYY, Ong TK
Europace: 29 Mar 2021; epub ahead of print | PMID: 33782701
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Impact:
Abstract

Cardiac operations and interventions during the COVID-19 pandemic: a nationwide perspective.

Leyva F, Zegard A, Okafor O, Stegemann B, Ludman P, Qiu T
Aims 
The COVID-19 pandemic has led to a decline in hospitalizations for non-COVID-19-related conditions. We explored the impact of the COVID-19 pandemic on cardiac operations and interventions undertaken in England.
Methods and results 
An administrative database covering hospital activity for England, the Health Episodes Statistics, was used to assess a total of 286 697 hospitalizations for cardiac operations and interventions, as well as 227 257 hospitalizations for myocardial infarction (MI) and 453 799 for heart failure (HF) from 7 January 2019 to 26 July 2020. Over the 3 months of \'lockdown\', total numbers and mean reductions in weekly rates [n (-%)], compared with the same time period in 2019, were: coronary artery bypass grafting [-2507 (-64%)]; percutaneous coronary intervention [-5245 (-28%)]; surgical [-1324 (-41%)] and transcatheter [-284 (-21%)] aortic valve replacement; mitral valve replacement; implantation of pacemakers [-6450 (-44%)], cardiac resynchronization therapy with [-356 (-42%)] or without [-491 (-46%)] defibrillation devices, and implantable cardioverter-defibrillators [-501 (-45%)]; atrial fibrillation ablation [-1902 (-83%)], and other ablations [-1712 (-64%)] (all P < 0.001). Over this period, there were 21 038 fewer procedures than in the reference period in 2019 (P < 0.001). These changes paralleled reductions in hospitalizations for MI [-10 794 (-27%)] and HF [-63 058 (-28%)] (both P < 0.001).
Conclusions 
The COVID-19 pandemic has led to substantial reductions in the number of cardiac operations and interventions undertaken. An alternative strategy for healthcare delivery to patients with cardiac conditions during the COVID-19 pandemic is urgently needed.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 28 Mar 2021; epub ahead of print
Leyva F, Zegard A, Okafor O, Stegemann B, Ludman P, Qiu T
Europace: 28 Mar 2021; epub ahead of print | PMID: 33778881
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Impact:
Abstract

Use of healthcare claims to validate the Prevention of Arrhythmia Device Infection Trial cardiac implantable electronic device infection risk score.

Ahmed FZ, Blomström-Lundqvist C, Bloom H, Cooper C, ... Lexcen DR, Krahn AD
Aim
The Prevention of Arrhythmia Device Infection Trial (PADIT) infection risk score, developed based on a large prospectively collected data set, identified five independent predictors of cardiac implantable electronic device (CIED) infection. We performed an independent validation of the risk score in a data set extracted from U.S. healthcare claims.
Methods and results
Retrospective identification of index CIED procedures among patients aged ≥18 years with at least one record of a CIED procedure between January 2011 and September 2014 in a U.S health claims database. PADIT risk factors and major CIED infections (with system removal, invasive procedure without system removal, or infection-attributable death) were identified through diagnosis and procedure codes. The data set was randomized by PADIT score into Data Set A (60%) and Data Set B (40%). A frailty model allowing multiple procedures per patient was fit using Data Set A, with PADIT score as the only predictor, excluding patients with prior CIED infection. A data set of 54 042 index procedures among 51 623 patients with 574 infections was extracted. Among patients with no history of prior CIED infection, a 1 unit increase in the PADIT score was associated with a relative 28% increase in infection risk. Prior CIED infection was associated with significant incremental predictive value (HR 5.66, P < 0.0001) after adjusting for PADIT score. A Harrell\'s C-statistic for the PADIT score and history of prior CIED infection was 0.76.
Conclusion
The PADIT risk score predicts increased CIED infection risk, identifying higher risk patients that could potentially benefit from targeted interventions to reduce the risk of CIED infection. Prior CIED infection confers incremental predictive value to the PADIT score.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 22 Mar 2021; epub ahead of print
Ahmed FZ, Blomström-Lundqvist C, Bloom H, Cooper C, ... Lexcen DR, Krahn AD
Europace: 22 Mar 2021; epub ahead of print | PMID: 33755136
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Impact:
Abstract

Clinical significance of J waves with respect to substrate characteristics and ablation outcomes in patients with arrhythmogenic right ventricular cardiomyopathy.

Lin CY, Chung FP, Lin YJ, Chang SL, ... Vicera JJB, Chen SA
Aims
J-wave syndrome in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) has been linked to an increased risk of ventricular arrhythmia. We investigated the significance of J waves with respect to substrate manifestations and ablation outcomes in patients with ARVC.
Methods and results
Forty-five patients with ARVC undergoing endocardial/epicardial mapping/ablation were studied. Patients were classified into two groups: 13 (28.9%) and 32 (71.1%) patients with and without J waves, respectively. The baseline characteristics, electrophysiological features, ventricular substrate, and recurrent ventricular tachycardia/fibrillation (VT/VF) were compared. Among the 13 patients with J waves, only the inferior J wave was observed. More ARVC patients with J waves fulfilled the major criteria of ventricular arrhythmias (76.9% vs. 21.9%, P = 0.003). Similar endocardial and epicardial substrate characteristics were observed between the two groups. However, patients with J waves had longer epicardial total activation time than those without (224.7 ± 29.9 vs. 200.8 ± 21.9 ms, P = 0.005). Concordance of latest endo/epicardial activation sites was observed in 29 (90.6%) patients without J waves and in none among those with J waves (P < 0.001). Complete elimination of endocardial/epicardial abnormal potentials resulted in the disappearance of the J wave in 8 of 13 (61.5%) patients. The VT/VF recurrences were not different between ARVC patients with and without J waves.
Conclusion
The presence of J waves was associated with the discordance of endocardial/epicardial activation pattern in terms of transmural depolarization discrepancy in patients with ARVC.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 17 Mar 2021; epub ahead of print
Lin CY, Chung FP, Lin YJ, Chang SL, ... Vicera JJB, Chen SA
Europace: 17 Mar 2021; epub ahead of print | PMID: 33734367
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Impact:
Abstract

Acute safety, efficacy, and advantages of a novel cryoballoon ablation system for pulmonary vein isolation in patients with paroxysmal atrial fibrillation: initial clinical experience.

Anic A, Lever N, Martin A, Breskovic T, ... Wazni OM, Varma N
Aims
Cryoballoon pulmonary vein isolation (PVI) is a safe and effective treatment for atrial fibrillation (AF). Current limitations include incomplete vein occlusion due to balloon rigidity and inconsistent electrogram recording, which impairs identification of isolation. We aimed to evaluate the acute safety and performance of a novel cryoballoon system.
Methods and results
The system includes a steerable sheath, mapping catheter, and a balloon that maintains uniform inflation pressure and size following initiation of ablation. Protocol-directed cryoablation was delivered for 180 s for isolation documented in ≤60 s, otherwise freeze duration was 240 s. Primary endpoints were acute safety and vein isolation. Pulmonary vein isolation was confirmed at ≥30 min post-isolation. Data were compared across vein locations. Thirty patients with paroxysmal AF were enrolled at two centres and underwent PVI. Pulmonary vein isolation was achieved with cryoablation only in 100% of veins (120/120). Nadir temperature was -53.1 ± 5.3°C. The number of applications to achieve PVI was 1.4 ± 0.4 per vein. Of the 120 veins, 89 were isolated with a single cryothermal application (10/30 patients required only 4 total cryoablations). There were no procedural- or device-related serious adverse events at 30 days post-procedure. A subset (24/30) of patients was followed for 1-year and 71% (17/24) remained free of atrial arrhythmias. Six patients with arrhythmia recurrence were remapped and three had durable PVI for all four veins.
Conclusion
In this first human experience, the novel cryoballoon platform was safe, efficacious, and demonstrated a high proportion of successful single ablation isolation.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 16 Mar 2021; epub ahead of print
Anic A, Lever N, Martin A, Breskovic T, ... Wazni OM, Varma N
Europace: 16 Mar 2021; epub ahead of print | PMID: 33729470
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Impact:
Abstract

Cryoballoon ablation vs. antiarrhythmic drugs: first-line therapy for patients with paroxysmal atrial fibrillation.

Kuniss M, Pavlovic N, Velagic V, Hermida JS, ... Chierchia GB, Cryo-FIRST Investigators
Aims
Treatment guidelines for patients with atrial fibrillation (AF) suggest that patients should be managed with an antiarrhythmic drug (AAD) before undergoing catheter ablation (CA). This study evaluated whether pulmonary vein isolation employing cryoballoon CA is superior to AAD therapy for the prevention of atrial arrhythmia (AA) recurrence in rhythm control naive patients with paroxysmal AF (PAF).
Methods and results
A total of 218 treatment naive patients with symptomatic PAF were randomized (1 : 1) to cryoballoon CA (Arctic Front Advance, Medtronic) or AAD (Class I or III) and followed for 12 months. The primary endpoint was ≥1 episode of recurrent AA (AF, atrial flutter, or atrial tachycardia) >30 s after a prespecified 90-day blanking period. Secondary endpoints included the rate of serious adverse events (SAEs) and recurrence of symptomatic palpitations (evaluated via patient diaries). Freedom from AA was achieved in 82.2% of subjects in the cryoballoon arm and 67.6% of subjects in the AAD arm (HR = 0.48, P = 0.01). There were no group differences in the time-to-first (HR = 0.76, P = 0.28) or overall incidence [incidence rate ratio (IRR)=0.79, P = 0.28] of SAEs. The incidence rate of symptomatic palpitations was lower in the cryoballoon (7.61 days/year) compared with the AAD arm (18.96 days/year; IRR = 0.40, P < 0.001).
Conclusions
Cryoballoon CA was superior to AAD therapy, significantly reducing AA recurrence in treatment naive patients with PAF. Additionally, cryoballoon CA was associated with lower symptom recurrence and a similar rate of SAEs compared with AAD therapy.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 16 Mar 2021; epub ahead of print
Kuniss M, Pavlovic N, Velagic V, Hermida JS, ... Chierchia GB, Cryo-FIRST Investigators
Europace: 16 Mar 2021; epub ahead of print | PMID: 33728429
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Impact:
Abstract

Single-dose oral anti-arrhythmic drugs for cardioversion of recent-onset atrial fibrillation: a systematic review and network meta-analysis of randomized controlled trials.

Ibrahim OA, Belley-Côté EP, Um KJ, Baranchuk A, ... Healey JS, McIntyre WF
Aims
Single oral dose anti-arrhythmic drugs (AADs) are used to cardiovert recent-onset atrial fibrillation (AF); however, the optimal agent is uncertain.
Methods
We performed a systematic review and network meta-analysis of randomized trials testing single oral dose AADs vs. any comparator to cardiovert AF <7 days duration. We searched MEDLINE, Embase, and CENTRAL to April 2020. The primary outcome was successful cardioversion at timepoint nearest 8 h after administration.
Results
From 12 712 citations, 22 trials (2320 patients) were included. Thirteen trials included patients with some degree of heart failure; 19 included patients with some degree of ischaemic heart disease vs. placebo or rate-control (32% success) at 8 h, flecainide [73%, network odds ratio (OR) 7.6, 95% credible interval (CrI) 4.4-14.0], propafenone (70%, OR 4.6, CrI 2.9-7.3), and pilsicainide (59%, OR 10.0, CrI 1.8-69.0), but not amiodarone (28%, OR 1.0, CrI 0.4-2.8) were superior. Flecainide (OR 7.5, CrI 2.6-24.0) and propafenone (OR 4.5, CrI 1.6-13.0) were superior to amiodarone; propafenone vs. flecainide did not statistically differ (OR 0.6, CrI 0.3-1.1). At longest follow-up, amiodarone was superior to placebo (OR 11.0, CrI 3.2-41.0), flecainide vs. amiodarone (OR 0.79, CrI 0.19-3.1), and propafenone vs. amiodarone (OR 0.36, CrI 0.092-1.4) were not statistically different, and flecainide was superior to propafenone (OR 2.2, CrI 1.1-4.8). Atrial and ventricular tachyarrhythmias, bradyarrhythmias, and hypotension were rare with PO AADs.
Conclusion
Single oral dose Class 1C AADs are effective and safe for cardioversion of recent-onset AF. Flecainide may be superior to propafenone. Amiodarone is a slower acting alternative.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 15 Mar 2021; epub ahead of print
Ibrahim OA, Belley-Côté EP, Um KJ, Baranchuk A, ... Healey JS, McIntyre WF
Europace: 15 Mar 2021; epub ahead of print | PMID: 33723602
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Impact:
Abstract

Prevalence of cardiac arrhythmias in cannabis use disorder related hospitalizations in teenagers from 2003 to 2016 in the United States.

Umapathi KK, Thavamani A, Dhanpalreddy H, Nguyen HH
Aims
Cannabis is an increasingly common recreational substance used by teenagers. However, there is limited data probing association of cardiac arrhythmias with marijuana use in this population.
Methods and results
We provide prevalence trends, disease burden and healthcare utilization of cardiac arrhythmias associated with cannabis use disorder (CUD) in hospitalized teenagers (13-20 years) using a large national administrative database in the United States from 2003-2016. We used partial least square regression analysis for assessing trends in prevalence of cardiac arrhythmias and multiple logistic regression to elucidate independent predictors of arrhythmias associated with CUD. Among all CUD related hospitalizations (n = 876, 431), 0.5% had arrhythmias. Prevalence trends of arrhythmias among CUD increased six-fold during the study period (P < 0.001). CUD was more prevalent in males and older teens (both P < 0.001). There was a significant risk for mortality when CUD was associated with arrhythmia (7.4% vs. 0.1%, P < 0.001). While mean length-of-stay (LOS) was shorter (4.4 vs. 5.4 days, P < 0.001) for patients with CUD, they incurred three times higher mean hospitalization charges when compared to CUD patients without arrhythmia ($45 959 vs. $18 986, P < 0.001). Both LOS and hospitalization charges showed an uptrend during the study period (P < 0.001). Congenital heart disease, congestive heart failure, hypertension, and obesity independently predicted arrhythmias in CUD while other substance abuse did not change the risk of arrhythmia in CUD.
Conclusion
Arrhythmia burden is increasing among teenagers with CUD, and co-occurrence of arrhythmia and CUD worsens hospital outcomes.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 15 Mar 2021; epub ahead of print
Umapathi KK, Thavamani A, Dhanpalreddy H, Nguyen HH
Europace: 15 Mar 2021; epub ahead of print | PMID: 33723583
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Impact:
Abstract

Use and misuse of instant messaging in clinical data sharing: the EHRA-SMS survey.

Guerra F, Linz D, Garcia R, Kommata V, ... Boveda S, Duncker D
Instant messaging (IM) enables medical professionals to quickly share clinical data to their peers for counselling. Purpose of this survey is to assess the habits related to IM, their application in clinical practice and the perceived pros and cons. An online survey was distributed to the medical community via newsletters, Twitter, LinkedIn, and Facebook. The survey consisted of 22 questions made on an individual-basis and collected anonymously on SurveyMonkey. A total of 287 subjects from 33 countries responded to the survey (mean age 43 years, 74.8% male). Of all respondents, 88.3% routinely send and 90.3% receive clinical data through IM which was second only to face-to-face contact as the preferred method for sharing clinical data. Twelve-lead electrocardiograms (88.6%), medical history (61.4%), and echo loops (55.7%) were the data shared most often. Nearly half of the clinical data that are sent (43%) or received (44%) are not anonymized. In the same way, 29.3% of the respondents were not aware of the European General Data Protection Regulation (GDPR) at the time of the survey. IM apps are used by medical professionals worldwide to share and discuss clinical data and are preferred to many other methods of data sharing, being second only to face-to-face contact. IM are often used to share many different types of clinical data, being perceived as a fast and easy way of communication. Medical professionals should be aware of the appropriate use of IM to prevent legal and privacy issues.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 11 Mar 2021; epub ahead of print
Guerra F, Linz D, Garcia R, Kommata V, ... Boveda S, Duncker D
Europace: 11 Mar 2021; epub ahead of print | PMID: 33709102
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Impact:
Abstract

Twitter for professional use in electrophysiology: practical guide for #EPeeps.

Linz D, Garcia R, Guerra F, Kommata V, Bollmann A, Duncker D
Social media (SoMe) becomes more and more popular in the cardiological community. Among them, Twitter is an emerging and dynamic medium to connect, communicate and educate academic and clinical cardiologists. However, in contrast to traditional scientific communications, the content provided through SoMe is not peer-reviewed and may not necessarily always represent scientific evidence or may even be used to unjustifiably promote therapies for commercial purposes. For the unintended, this means of communication might be appear difficult to handle. This article aims to provide a practical guide on how to use Twitter efficiently for professional use to keep yourself up-to-date about new techniques, the latest study results and news presented at national or international conferences. Additionally, important limitations will be discussed.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 11 Mar 2021; epub ahead of print
Linz D, Garcia R, Guerra F, Kommata V, Bollmann A, Duncker D
Europace: 11 Mar 2021; epub ahead of print | PMID: 33829263
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Impact:
Abstract

Five cases of complete atrioventricular block induced by bending forward: unusual but not unique.

Saal DP, Thijs RD, Bootsma M, Brignole M, van Dijk JG
Aims
We describe five patients with syncope caused by a complete atrioventricular block (AVB) while they were bending forward, not rising after bending, and aim to describe the occurrence and the association between bending forward and AVB.
Methods and results
In two patients, bending forward was the exclusive trigger for syncope, while in the remaining three, other postural changes (sitting down, standing up, and exertion) could also provoke syncope. Complete AVB as the cause of syncope was documented using ECG monitoring in two cases and an implantable loop recorder in the other three. Ectopic beats without preceding sinus slowing occurred before syncope in four cases. Two cases had a left bundle branch block. All patients responded favourably to cardiac pacing.
Conclusion
This is the first case series on complete AVB provoked by bending forward. Syncope during bending forward should suggest a search for an AVB. Arguments in favour of a vagal mechanism were syncope triggered by bending forward, and that other triggers could also evoke syncope. However, the absence of sinus slowing before syncope in some cases and the fact that bending forward did not seem to provoke reflex syncope without AVB, cast doubts on a reflex mechanism. There were also arguments favouring conduction disorder: i.e. ectopic beats before syncope and pre-existing conduction disturbances in two cases. The cases are reminiscent of paroxysmal AVB. Discrimination between paroxysmal AVB and vagal AVB is important because a pacemaker is warranted in arrhythmic complete AVB, while the benefit is limited or absent in reflex AVB.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 09 Mar 2021; epub ahead of print
Saal DP, Thijs RD, Bootsma M, Brignole M, van Dijk JG
Europace: 09 Mar 2021; epub ahead of print | PMID: 33693701
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Impact:
Abstract

Catheter ablation for non-paroxysmal atrial fibrillation accompanied by heart failure with preserved ejection fraction: feasibility and benefits in functions and B-type natriuretic peptide.

Yamauchi R, Morishima I, Okumura K, Kanzaki Y, ... Sakamoto G, Murohara T
Aims
We aimed to examine the benefits of catheter ablation in patients with non-paroxysmal atrial fibrillation (AF) accompanied by heart failure (HF) with preserved ejection fraction (HFpEF), in comparison with the benefits in patients with AF accompanied by HF with reduced ejection fraction (HFrEF) or patients with no HF.
Methods and results
From 1173 consecutive patients undergoing catheter ablation, 502 with non-paroxysmal AF were divided into three groups: no history of HF [plasma B-type natriuretic peptide (BNP) <100 pg/mL and no HF hospitalization; n = 125], HFpEF [left ventricular (LV) EF ≥50%; n = 293], and HF with midrange EF (HFmrEF) + HFrEF (LVEF <50%; n = 84) groups. The endpoints were AF recurrence at 1 year, changes in symptomatic and image-based functional status, and changes in BNP levels from baseline to 1 year. In the HFpEF group, AF recurred in 48 patients (16.4%) and 278 patients (94.8%) had sinus rhythm at 1 year; these values were comparable with those in the other groups. Significant improvement was observed in the left atrial diameter, LVEF, and New York Heart Association functional class in the HFpEF and HFmrEF + HFrEF groups. The BNP level significantly decreased irrespective of the index rate control status, and freedom from AF recurrence was an independent predictor of HF remission, defined as BNP <100 pg/mL at 1 year, in the HFpEF group.
Conclusion
Catheter ablation is highly feasible for restoring sinus rhythm in non-paroxysmal AF with coexisting HFpEF, thereby improving cardiac function and BNP levels. Catheter ablation for AF may be an optional management strategy.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 09 Mar 2021; epub ahead of print
Yamauchi R, Morishima I, Okumura K, Kanzaki Y, ... Sakamoto G, Murohara T
Europace: 09 Mar 2021; epub ahead of print | PMID: 33693617
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Impact:
Abstract

Left atrial phasic transport function closely correlates with fibrotic and arrhythmogenic atrial tissue degeneration in atrial fibrillation patients: cardiac magnetic resonance feature tracking and voltage mapping.

Schönbauer R, Tomala J, Kirstein B, Huo Y, ... Ulbrich S, Piorkowski C
Aims
To characterize the association of phasic left atrial (LA) transport function and LA fibrosis guided by multimodality imaging containing cardiac magnetic resonance imaging (CMR) feature tracking and bipolar voltage mapping.
Methods and results
Consecutive patients presenting for first-time ablation of atrial fibrillation (AF) were prospectively enrolled. Each patient underwent CMR prior to the ablation procedure. LA phasic indexed volumes (LA-Vi) and emptying fractions (LA-EF) were calculated and CMR feature tracking guided LA wall motion analysis was performed. LA bipolar voltage mapping was carried out in sinus rhythm to find areas of low voltage as a surrogate for fibrosis and arrhythmogenesis. One hundred and sixty-eight patients were enrolled. Low-voltage areas (LVAs) were present in 70 patients (42%). Contrary to LA volume, CMR based LA-EF [odds ratio (OR) 0.88, 95% confidence interval (CI) 0.80-0.96, P = 0.005] and LA booster pump strain rate (SR) (OR 0.98, 95% CI 0.97-0.99, P = 0.001) significantly predicted presence and extent of LVA in multivariate logistic regression analysis for patients scanned in SR. In receiver operating characteristic analysis, LA-EF <40% carried a sensitivity of 83% and specificity of 76% (area under the curve 0.8; 95% CI 0.71-0.89) to predict presence of LVA. For patients scanned in AF only minimal LA-Vi on CMR (OR: 1.06; 95% CI: 1.02-1.10; P = 0.002) predicted presence of LVA.
Conclusion
For patients scanned in SR LA-EF and LA booster pump SR are closely linked to the presence and extent of LA LVA.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 08 Mar 2021; epub ahead of print
Schönbauer R, Tomala J, Kirstein B, Huo Y, ... Ulbrich S, Piorkowski C
Europace: 08 Mar 2021; epub ahead of print | PMID: 33693595
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Impact:
Abstract

Atrial fibrillation ablation in heart failure: What do we know? What can we do?

Chiocchini A, Terricabras M, Verma A
Atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) are two conditions that frequently impact reciprocally on each other. Patients with HFrEF have an increased risk of stroke, hospitalization and mortality after they develop AF and vice versa, AF causing deterioration of the ejection fraction is also associated to increased mortality. Catheter ablation has emerged as an effective alternative to antiarrhythmic drug treatment to maintain sinus rhythm and some randomized trials have shown a potential benefit in terms of mortality and hospitalization. This review discusses the available evidence regarding catheter ablation treatment in this specific patient group.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 07 Mar 2021; 23:353-361
Chiocchini A, Terricabras M, Verma A
Europace: 07 Mar 2021; 23:353-361 | PMID: 33083820
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Impact:
Abstract

Reprocessing of electrophysiology material in EHRA countries: an EHRA Young EP survey.

Duncker D, Svetlosak M, Guerra F, Nagy KV, ... Mikhaylov EN, Kosiuk J
Data on reprocessing of electrophysiology (EP) materials are sparse. Reprocessing of catheters and other materials in daily routine varies through countries and may depend on specific material characteristics, supplier, or federal law. The aim of this study was to collect data on reprocessing usage through EHRA countries. An online survey consisting of 27 questions was distributed to EHRA Young EP members and members of national EP working groups. Two hundred and two participants from 34 EHRA countries completed the survey. One hundred and seven respondents (53.0%) reported having used and using reprocessed EP material, 30 (14.9%) respondents have used reprocessed EP material in the past but not at the time of the survey, 65 (32.2%) had never used reprocessed EP material. The most reprocessed EP materials include cables (70%), diagnostic EP catheters with deflectable (64%) or fixed curve (63%), non-irrigated ablation catheters (51%), and other conventional diagnostic catheters (41%). The most durable material was diagnostic EP catheters with a fixed curve (61%), the most sensitive material was ablation catheters with contact force sensors (21%). Important benefits were seen in reducing costs for the providing hospital (65%) and the healthcare provider (42%) and making EP procedures available for a greater number of patients (42%). Main concerns were on quality aspects (58%), contamination (52%), and loss of precision (47%). Reprocessing of EP materials is heterogeneously managed among EHRA countries. The present survey shows that European electrophysiologists consider the use of reprocessed EP material as generally safe and cost-effective.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 07 Mar 2021; 23:479-485
Duncker D, Svetlosak M, Guerra F, Nagy KV, ... Mikhaylov EN, Kosiuk J
Europace: 07 Mar 2021; 23:479-485 | PMID: 33083819
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Impact:
Abstract

Multi-catheter cryotherapy compared with radiofrequency ablation in long-standing persistent atrial fibrillation: a randomized clinical trial.

Gallagher MM, Yi G, Gonna H, Leung LWM, ... Zuberi Z, Camm AJ
Aims
Restoring sinus rhythm (SR) by ablation alone is an endpoint used in radiofrequency (RF) ablation for long-standing persistent atrial fibrillation (AF) but not with cryotherapy. The simultaneous use of two cryotherapy catheters can improve ablation efficiency; we compared this with RF ablation in chronic persistent AF aiming for termination to SR by ablation alone.
Methods and results
Consecutive patients undergoing their first ablation for persistent AF of >6 months duration were screened. A total of 100 participants were randomized 1:1 to multi-catheter cryotherapy or RF. For cryotherapy, a 28-mm Arctic Front Advance was used in tandem with focal cryoablation catheters. Open-irrigated, non-force sensing catheters were used in the RF group with a 3D mapping system. Pulmonary vein (PV) isolation and non-PV triggers were targeted. Participants were followed up at 6 and 12 months, then yearly. Acute PVI was achieved in all cases. More patients in the multi-catheter cryotherapy group were restored to SR by ablation alone, with a shorter procedure duration. Sinus rhythm continued to the last available follow-up in 16/49 patients (33%) in the multi-catheter at 3.0 ± 1.6 years post-ablation and in 12/50 patients (24%) in the RF group at 4.0 ± 1.2 years post-ablation. The yearly rate of arrhythmia recurrence was similar.
Conclusion
Multi-catheter cryotherapy can restore SR by ablation alone in more cases and more quickly than RF ablation. Long-term success is difficult to achieve by either methods and is similar with both.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 07 Mar 2021; 23:370-379
Gallagher MM, Yi G, Gonna H, Leung LWM, ... Zuberi Z, Camm AJ
Europace: 07 Mar 2021; 23:370-379 | PMID: 33188692
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Impact:
Abstract

Efficacy of multi-electrode linear irreversible electroporation.

Buist TJ, Groen MHA, Wittkampf FHM, Loh P, ... van Es R, Elvan A
Aims
We investigated the efficacy of linear multi-electrode irreversible electroporation (IRE) ablation in a porcine model.
Methods and results
The study was performed in six pigs (weight 60-75 kg). After median sternotomy and opening of the pericardium, a pericardial cradle was formed and filled with blood. A linear seven polar 7-Fr electrode catheter with 2.5 mm electrodes and 2.5 mm inter-electrode spacing was placed in good contact with epicardial tissue. A single IRE application was delivered using 50 J at one site and 100 J at two other sites, in random sequence, using a standard monophasic defibrillator connected to all seven electrodes connected in parallel. The pericardium and thorax were closed and after 3 weeks survival animals were euthanized. A total of 82 histological sections from all 18 electroporation lesions were analysed. A total of seven 50 J and fourteen 100 J epicardial IRE applications were performed. Mean peak voltages at 50 and 100 J were 1079.2 V ± 81.1 and 1609.5 V ± 56.8, with a mean peak current of 15.4 A ± 2.3 and 20.2 A ± 1.7, respectively. Median depth of the 50 and 100 J lesions were 3.2 mm [interquartile range (IQR) 3.1-3.6] and 5.5 mm (IQR 4.6-6.6) (P < 0.001), respectively. Median lesion width of the 50 and 100 J lesions was 3.9 mm (IQR 3.7-4.8) and 5.4 mm (IQR 5.0-6.3), respectively (P < 0.001). Longitudinal sections showed continuous lesions for 100 J applications.
Conclusion
Epicardial multi-electrode linear application of IRE pulses is effective in creating continuous deep lesions.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 07 Mar 2021; 23:464-468
Buist TJ, Groen MHA, Wittkampf FHM, Loh P, ... van Es R, Elvan A
Europace: 07 Mar 2021; 23:464-468 | PMID: 33200191
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Impact:
Abstract

Infanticide vs. inherited cardiac arrhythmias.

Brohus M, Arsov T, Wallace DA, Jensen HH, ... Overgaard MT, Schwartz PJ
Aims
In 2003, an Australian woman was convicted by a jury of smothering and killing her four children over a 10-year period. Each child died suddenly and unexpectedly during a sleep period, at ages ranging from 19 days to 18 months. In 2019 we were asked to investigate if a genetic cause could explain the children\'s deaths as part of an inquiry into the mother\'s convictions.
Methods and results
Whole genomes or exomes of the mother and her four children were sequenced. Functional analysis of a novel CALM2 variant was performed by measuring Ca2+-binding affinity, interaction with calcium channels and channel function. We found two children had a novel calmodulin variant (CALM2 G114R) that was inherited maternally. Three genes (CALM1-3) encode identical calmodulin proteins. A variant in the corresponding residue of CALM3 (G114W) was recently reported in a child who died suddenly at age 4 and a sibling who suffered a cardiac arrest at age 5. We show that CALM2 G114R impairs calmodulin\'s ability to bind calcium and regulate two pivotal calcium channels (CaV1.2 and RyR2) involved in cardiac excitation contraction coupling. The deleterious effects of G114R are similar to those produced by G114W and N98S, which are considered arrhythmogenic and cause sudden cardiac death in children.
Conclusion
A novel functional calmodulin variant (G114R) predicted to cause idiopathic ventricular fibrillation, catecholaminergic polymorphic ventricular tachycardia, or mild long QT syndrome was present in two children. A fatal arrhythmic event may have been triggered by their intercurrent infections. Thus, calmodulinopathy emerges as a reasonable explanation for a natural cause of their deaths.

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 07 Mar 2021; 23:441-450
Brohus M, Arsov T, Wallace DA, Jensen HH, ... Overgaard MT, Schwartz PJ
Europace: 07 Mar 2021; 23:441-450 | PMID: 33200177
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Impact:
Abstract

Complications related to elective generator replacement of the subcutaneous implantable defibrillator.

van der Stuijt W, Quast ABE, Baalman SWE, de Wilde KC, ... Wilde AAM, Knops RE
Aims
To guarantee uninterrupted function of the subcutaneous implantable cardioverter-defibrillator (S-ICD), the pulse generator needs to be surgically replaced before the battery is depleted. The risks related to this replacement substantially impact long-term outcome for S-ICD recipients, as the majority will undergo one or several of these procedures in their lifetime. We aim to describe the procedural characteristics of the replacement procedure and to provide an insight in the complications associated with these replacements.
Methods and results
In this retrospective analysis, data from replacement procedures and follow-up visits were collected from all patients who underwent elective S-ICD generator replacement in our tertiary centre from June 2014 until November 2019. Original device position was assessed using the PRAETORIAN score. Complications were defined as those requiring surgical intervention, systemic antibiotic treatment, or device extraction. Seventy-two patients were included, with a median follow-up of 1.9 years (IQR 0.6-3.3 years) after replacement. Battery depletion occurred after 5.9 ± 0.7 years. The pulse generator was repositioned in patients with a PRAETORIAN score ≥90 to minimize the defibrillation threshold. Although there was an increase in impedance compared to the implant procedure, first shock conversion rate during defibrillation testing was 91.4% with a success rate of 100% after multiple attempts. Two patients developed a complication after, respectively, 9 and 21 months, resulting in a complication rate of 1.4% per year.
Conclusion
With a median follow-up of 1.9 years, this study shows a low complication rate after S-ICD replacement, with a first shock conversion rate of 91.4%.

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 07 Mar 2021; 23:395-399
van der Stuijt W, Quast ABE, Baalman SWE, de Wilde KC, ... Wilde AAM, Knops RE
Europace: 07 Mar 2021; 23:395-399 | PMID: 33197266
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Impact:
Abstract

Clinical outcomes and programming strategies of implantable cardioverter-defibrillator devices in paediatric hypertrophic cardiomyopathy: a UK National Cohort Study.

Norrish G, Chubb H, Field E, McLeod K, ... Mangat J, Kaski JP
Aims
Sudden cardiac death (SCD) is the most common mode of death in paediatric hypertrophic cardiomyopathy (HCM). This study describes the implant and programming strategies with clinical outcomes following implantable cardioverter-defibrillator (ICD) insertion in a well-characterized national paediatric HCM cohort.
Methods and results
Data from 90 patients undergoing ICD insertion at a median age 13 (±3.5) for primary (n = 67, 74%) or secondary prevention (n = 23, 26%) were collected from a retrospective, longitudinal multi-centre cohort of children (<16 years) with HCM from the UK. Seventy-six (84%) had an endovascular system [14 (18%) dual coil], 3 (3%) epicardial, and 11 (12%) subcutaneous system. Defibrillation threshold (DFT) testing was performed at implant in 68 (76%). Inadequate DFT in four led to implant adjustment in three patients. Over a median follow-up of 54 months (interquartile range 28-111), 25 (28%) patients had 53 appropriate therapies [ICD shock n = 45, anti-tachycardia pacing (ATP) n = 8], incidence rate 4.7 per 100 patient years (95% CI 2.9-7.6). Eight inappropriate therapies occurred in 7 (8%) patients (ICD shock n = 4, ATP n = 4), incidence rate 1.1/100 patient years (95% CI 0.4-2.5). Three patients (3%) died following arrhythmic events, despite a functioning device. Other device complications were seen in 28 patients (31%), including lead-related complications (n = 15) and infection (n = 10). No clinical, device, or programming characteristics predicted time to inappropriate therapy or lead complication.
Conclusion
In a large national cohort of paediatric HCM patients with an ICD, device and programming strategies varied widely. No particular strategy was associated with inappropriate therapies, missed/delayed therapies, or lead complications.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 07 Mar 2021; 23:400-408
Norrish G, Chubb H, Field E, McLeod K, ... Mangat J, Kaski JP
Europace: 07 Mar 2021; 23:400-408 | PMID: 33221861
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Impact:
Abstract

Pediatric catheter ablation at the beginning of the 21st century: results from the European Multicenter Pediatric Catheter Ablation Registry \'EUROPA\'.

Krause U, Paul T, Bella PD, Gulletta S, ... Ferrari P, De Filippo P
Aims
Contemporary data from prospective multicentre registries on catheter ablation in pediatric patients are sparse. Aim of the European Pediatric Catheter Ablation Registry EUROPA was to contribute data to fill this gap of knowledge.
Methods and results
From July 2012 to June 2017, data on catheter ablation in pediatric patients (≤18 years of age) including a 1-year follow-up from five European pediatric EP centres were collected prospectively. A total of 683 patients (mean age 12.4 ± 3.9 years, mean body weight 50.2 ± 19 kg) were enrolled. Target tachycardia was WPW/atrioventricular-nodal re-entrant tachycardia (AVRT) in 380 (55.7%) patients, AVNRT in 230 (33.8%) patients, ventricular tachycardia (VT) in 24 (3.5) patients, focal atrial tachycardia (FAT) in 20 (2.9%) patients, IART in 14 (2%) patients, and junctional ectopic tachycardia in 3 (0.45) patients. Overall procedural success was 95.6%. Compared with all other substrates, success was significantly lower in FAT patients (80%, n = 16, P = 0.001). Mean procedure duration was 136 ± 67 min and mean fluoroscopy time was 4.9 ± 6.8 min. Major complications occurred in 0.7% of the patients. No persisting AV block requiring permanent pacing was reported. At 1-year follow-up (605/683 patients, 95%), tachycardia recurrence was reported in 7.8% of patients. Recurrence after VT ablation (33%) was significantly higher (P = 0.001) than after ablation of all other substrates.
Conclusion
The present study proves overall high efficacy and safety of catheter ablation of various tachycardia substrates in pediatric patients. Of note, complication rate was exceptionally low. Long-term success was high except for patients after VT ablation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 07 Mar 2021; 23:431-440
Krause U, Paul T, Bella PD, Gulletta S, ... Ferrari P, De Filippo P
Europace: 07 Mar 2021; 23:431-440 | PMID: 33227133
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Abstract

Accuracy of left atrial fibrosis detection with cardiac magnetic resonance: correlation of late gadolinium enhancement with endocardial voltage and conduction velocity.

Caixal G, Alarcón F, Althoff TF, Nuñez-Garcia M, ... Guasch E, Mont L
Aims
Myocardial fibrosis is a hallmark of atrial fibrillation (AF) and its characterization could be used to guide ablation procedures. Late gadolinium enhanced-magnetic resonance imaging (LGE-MRI) detects areas of atrial fibrosis. However, its accuracy remains controversial. We aimed to analyse the accuracy of LGE-MRI to identify left atrial (LA) arrhythmogenic substrate by analysing voltage and conduction velocity at the areas of LGE.
Methods and results
Late gadolinium enhanced-magnetic resonance imaging was performed before ablation in 16 patients. Atrial wall intensity was normalized to blood pool and classified as healthy, interstitial fibrosis, and dense scar tissue depending of the resulting image intensity ratio. Bipolar voltage and local conduction velocity were measured in LA with high-density electroanatomic maps recorded in sinus rhythm and subsequently projected into the LGE-MRI. A semi-automatic, point-by-point correlation was made between LGE-MRI and electroanatomical mapping. Mean bipolar voltage and local velocity progressively decreased from healthy to interstitial fibrosis to scar. There was a significant negative correlation between LGE with voltage (r = -0.39, P < 0.001) and conduction velocity (r = -0.25, P < 0.001). In patients showing dilated atria (LA diameter ≥45 mm) the conduction velocity predictive capacity of LGE-MRI was weaker (r = -0.40 ± 0.09 vs. -0.20 ± 0.13, P = 0.02).
Conclusions
Areas with higher LGE show lower voltage and slower conduction in sinus rhythm. The enhancement intensity correlates with bipolar voltage and conduction velocity in a point-by-point analysis. The performance of LGE-MRI in assessing local velocity might be reduced in patients with dilated atria (LA diameter ≥45).

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 07 Mar 2021; 23:380-388
Caixal G, Alarcón F, Althoff TF, Nuñez-Garcia M, ... Guasch E, Mont L
Europace: 07 Mar 2021; 23:380-388 | PMID: 33227129
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Abstract

Cryoablation vs. radiofrequency ablation of the atrioventricular node in patients with His-bundle pacing.

Zweerink A, Bakelants E, Stettler C, Burri H
Aims
Radiofrequency ablation (RFA) of the atrioventricular node (AVN) with His-bundle pacing (HBP) can cause rise in capture thresholds. Cryoablation (CRYO) may offer reversibility in case of threshold rise but has never been tested for AVN ablation in this setting. Our aim was to compare procedural characteristics and outcome of CRYO compared with RFA for AVN ablation in patients with HBP.
Methods and results
Forty-four patients with HBP underwent AVN ablation for an \'ablate and pace\' indication. Cryoablation was performed in the first 22 patients and RFA in the following 22 patients. Procedural characteristics, success rates, and change in His capture thresholds were compared between groups. Distance from the ablation site to the His lead was measured using biplane fluoroscopy. Acute success was 100% with both strategies. Median procedural duration was significantly longer for CRYO {50 [interquartile range (IQR) 38-63] min} compared with RFA [36 (IQR, 30-41) min; P = 0.027]. An acute threshold rise of ≥1 V was observed in four CRYO (one complete loss of capture) and three RFA patients (P = 0.38), with all of the applications being within 6 mm of the His lead tip. During follow-up, nine patients had AVN re-conduction (six CRYO vs. three RFA; P = 0.58), but only four patients required a redo procedure (all CRYO; P = 0.09).
Conclusion
Cryoablation does not offer any advantage over RFA for AVN ablation in patients with HBP and tended to require more redo procedures. If possible, a distance of ≥6 mm should be maintained from the His lead tip to avoid a rise in capture thresholds.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 07 Mar 2021; 23:421-430
Zweerink A, Bakelants E, Stettler C, Burri H
Europace: 07 Mar 2021; 23:421-430 | PMID: 33241283
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Abstract

Impact of electroanatomical mapping-guided lead implantation on procedural outcome of His bundle pacing.

Richter S, Ebert M, Bertagnolli L, Gebauer R, ... Hindricks G, Döring M
Aims
Conventional His bundle pacing (HBP) can be technically challenging and fluoroscopy-intense, particularly in patients with His-Purkinje conduction disease (HPCD). Three-dimensional electroanatomical mapping (EAM) facilitates non-fluoroscopic lead navigation and HB electrogram mapping. We sought to assess the procedural outcome of routine EAM-guided HBP compared with conventional HBP in a real-world population and evaluate the feasibility and safety of EAM-guided HBP in patients with HPCD.
Methods and results 
We included 58 consecutive patients (72 ± 13 years; 71% male) who underwent an attempt to conventional (EAM- group; n = 29) or EAM-guided (EAM+ group; n = 29) HBP between June 2019 and April 2020. The centre\'s learning curve was initially determined (n = 40 cases) to define the conventional control group and minimize outcome bias favouring EAM-guided HBP. His bundle pacing was successful in 26 patients (90%) in the EAM+ and 27 patients (93%) in the EAM- group (P = 0.64). The procedure time was 90 (73-135) and 110 (70-130) min, respectively (P = 0.89). The total fluoroscopy time [0.7 (0.5-1.4) vs. 3.3 (1.4-6.5) min; P < 0.001] and fluoroscopy dose [21.9 (9.1-47.7) vs. 78.6 (27.2-144.9) cGycm2; P = 0.001] were significantly lower in the EAM+ than EAM- group. There were no significant differences between groups in His capture threshold (1.2 ± 0.6 vs. 1.4 ± 1.0 V/1.0 ms; P = 0.33) and paced QRS duration (113 ± 15 vs. 113 ± 17 ms; P = 0.89). In patients with HPCD, paced QRS duration was similar in both groups (121 ± 15 vs. 123 ± 12 ms; P = 0.77). The bundle branch-block recruitment threshold tended to be lower in the EAM+ than EAM- group (1.3 ± 0.7 vs. 1.8 ± 1.2 V/1.0 ms; P = 0.31). No immediate procedure-related complications occurred. One patient (2%) experienced lead dislodgement during 4-week follow-up.
Conclusion 
Implementation of routine EAM-guided HBP lead implantation is feasible and safe in a real-world cohort of patients with and without HPCD and results in a tremendous reduction in radiation exposure without prolonging procedure time or increasing procedure-related complications.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 07 Mar 2021; 23:409-420
Richter S, Ebert M, Bertagnolli L, Gebauer R, ... Hindricks G, Döring M
Europace: 07 Mar 2021; 23:409-420 | PMID: 33253376
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Abstract

FRAGILE: FRench Attitude reGistry in case of ICD LEad replacement.

Alonso C, Marquie C, Defaye P, Clementy N, ... Deharo JC, “groupe Rythmologie—Stimulation cardiaque de la société française de cardiologie”
Aims
FRench Attitude reGistry in case of ICD LEad replacement (FRAGILE) registry was set-up to describe the attitude in different French institutions in case of implantable cardioverter-defibrillator (ICD) lead replacement, extraction, or abandonment and to compare outcomes in both groups.
Methods and results
Prospective observational study comparing two attitudes in case of ICD lead replacement, extraction, or abandonment. Primary endpoint describes the attitude in different French centres, collect parameters that may influence the decision. Secondary endpoint compares early and mid-term (2 years) complications in both groups.Between April 2013 and April 2017, 552 patients were included in 32 centres. 434 (78.6%) were male, mean patient\'s age was 60.3 ± 14.4 years. In 56.9% of the cases, the decision was to explant the lead. Patients in the extraction group were younger than in the abandonment group (56.7 ± 14.5 vs. 65 ± 12.7 P < 0.0001) and less likely to have comorbidities (46.5% vs. 58.3% of the patients P = 0.022). The mean lead dwelling time was significantly longer in the abandonment group as compared with the extraction group (7.6 ± 3.9 vs. 5.2 ± 3.1 years, P < 0.0001). There was no statistical difference between both groups concerning early and 2 years complications.
Conclusion
In this registry, the strategy in case of non-infected ICD lead replacement was mainly influenced by patient\'s age and comorbidities and lead dwelling time. No difference was observed in outcomes in both strategies.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 07 Mar 2021; 23:389-394
Alonso C, Marquie C, Defaye P, Clementy N, ... Deharo JC, “groupe Rythmologie—Stimulation cardiaque de la société française de cardiologie”
Europace: 07 Mar 2021; 23:389-394 | PMID: 33257986
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Impact:
Abstract

Catheter ablation or medical therapy to delay progression of atrial fibrillation: the randomized controlled atrial fibrillation progression trial (ATTEST).

Kuck KH, Lebedev DS, Mikhaylov EN, Romanov A, ... Willems S, Ouyang F
Aims
Delay of progression from paroxysmal to persistent atrial fibrillation (AF) is an important measure of long-term success of AF treatment. However, published data on the impact of catheter ablation on AF progression are limited. This study evaluates whether radiofrequency (RF) catheter ablation delays the progression of AF compared with antiarrhythmic drug (AAD) treatment using current AF management guidelines.
Methods
This prospective, randomized, controlled, two-arm, open-label trial was conducted at 29 hospitals and medical centres across 13 countries. Patients were randomized 1 : 1 to RF ablation or AAD treatment. The primary endpoint was the rate of persistent AF/atrial tachycardia (AT) at 3 years.
Results
After early study termination following slow enrolment, 255 (79%) of the planned 322 patients were enrolled (RF ablation, n = 128, AAD, n = 127); 36% of patients in the RF ablation group and 41% in the AAD group completed 3 years of follow-up. For the primary endpoint, the Kaplan-Meier estimate of the rate of persistent AF/AT at 3 years was significantly lower with RF ablation [2.4% (95% confidence interval (CI), 0.6-9.4%)] than with AAD therapy [17.5% (95% CI, 10.7-27.9%); one-sided P = 0.0009]. Patients ≥65 years were ∼4 times more likely to progress to persistent AF/AT than patients <65 years, suggesting RF ablation can delay disease progression [hazard ratio: 3.87 (95% CI, 0.88-17.00); P = 0.0727]. Primary adverse events were reported for eight patients in the RF ablation group.
Conclusions
Radiofrequency ablation is superior to guideline-directed AAD therapy in delaying the progression from paroxysmal to persistent AF.

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 07 Mar 2021; 23:362-369
Kuck KH, Lebedev DS, Mikhaylov EN, Romanov A, ... Willems S, Ouyang F
Europace: 07 Mar 2021; 23:362-369 | PMID: 33330909
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Impact:
Abstract

Sinus rhythm voltage fingerprinting in patients with mitral valve disease using a high-density epicardial mapping approach.

van Schie MS, Starreveld R, Bogers AJJC, de Groot NMS
Aims
Unipolar voltage (UV) mapping is increasingly used for guiding ablative therapy of atrial fibrillation (AF) as unipolar electrograms (U-EGMs) are independent of electrode orientation and atrial wavefront direction. This study was aimed at constructing individual, high-resolution sinus rhythm (SR) UV fingerprints to identify low-voltage areas and study the effect of AF episodes in patients with mitral valve disease (MVD).
Methods and results
Intra-operative epicardial mapping (interelectrode distance 2 mm) of the right and left atrium, Bachmann\'s bundle (BB), and pulmonary vein area was performed in 67 patients (27 male, 67 ± 11 years) with or without a history of paroxysmal AF (PAF). In all patients, there were considerable regional variations in voltages. UVs at BB were lower in patients with PAF compared with those without [no AF: 4.94 (3.56-5.98) mV, PAF: 3.30 (2.25-4.57) mV, P = 0.006]. A larger number of low-voltage potentials were recorded at BB in the PAF group [no AF: 2.13 (0.52-7.68) %, PAF: 12.86 (3.18-23.59) %, P = 0.001]. In addition, areas with low-voltage potentials were present in all patients, yet we did not find any predilection sites for low-voltage potentials to occur.
Conclusion
Even in SR, advanced atrial remodelling in MVD patients shows marked inter-individual and regional variation. Low UVs are even present during SR in patients without a history of AF indicating that low UVs should carefully be used as target sites for ablative therapy.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 07 Mar 2021; 23:469-478
van Schie MS, Starreveld R, Bogers AJJC, de Groot NMS
Europace: 07 Mar 2021; 23:469-478 | PMID: 33432326
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Abstract

Dynamic risk assessment to improve quality of care in patients with atrial fibrillation: the 7th AFNET/EHRA Consensus Conference.

Fabritz L, Crijns HJGM, Guasch E, Goette A, ... Schotten U, Kirchhof P
Aims
The risk of developing atrial fibrillation (AF) and its complications continues to increase, despite good progress in preventing AF-related strokes.
Methods and results
This article summarizes the outcomes of the 7th Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA) held in Lisbon in March 2019. Sixty-five international AF specialists met to present new data and find consensus on pressing issues in AF prevention, management and future research to improve care for patients with AF and prevent AF-related complications. This article is the main outcome of an interactive, iterative discussion between breakout specialist groups and the meeting plenary. AF patients have dynamic risk profiles requiring repeated assessment and risk-based therapy stratification to optimize quality of care. Interrogation of deeply phenotyped datasets with outcomes will lead to a better understanding of the cardiac and systemic effects of AF, interacting with comorbidities and predisposing factors, enabling stratified therapy. New proposals include an algorithm for the acute management of patients with AF and heart failure, a call for a refined, data-driven assessment of stroke risk, suggestions for anticoagulation use in special populations, and a call for rhythm control therapy selection based on risk of AF recurrence.
Conclusion
The remaining morbidity and mortality in patients with AF needs better characterization. Likely drivers of the remaining AF-related problems are AF burden, potentially treatable by rhythm control therapy, and concomitant conditions, potentially treatable by treating these conditions. Identifying the drivers of AF-related complications holds promise for stratified therapy.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 07 Mar 2021; 23:329-344
Fabritz L, Crijns HJGM, Guasch E, Goette A, ... Schotten U, Kirchhof P
Europace: 07 Mar 2021; 23:329-344 | PMID: 33555020
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Abstract

Likelihood of injury due to vasovagal syncope: a systematic review and meta-analysis.

Jorge JG, Raj SR, Teixeira PS, Teixeira JAC, Sheldon RS
Aims
Vasovagal syncope (VVS) is the most common type of syncope and is usually considered a benign disorder. The potential for injury is worrisome but the likelihood is unknown. We aimed to determine the proportion of patients injured due to VVS.
Methods and results
A systematic search of studies published until August 2020 was performed in multiple medical and nursing databases. Included studies had data on the proportion of patients with injury due to VVS prior to study enrolment. Random effects methods were used. Twenty-three studies having 3593 patients met inclusion criteria. Patients were diagnosed clinically with VVS, and 82% had >2 syncopal episodes before enrolment. Tilt test was positive in 60% and 14 studies reported comorbidities (32.6% hypertensive). The weighted mean injury rate was 33.5% [95% confidence interval (CI): 27.3-40.5%]. The likelihood of injury correlated with population age (r = 0.4, P = 0.05), but not with sex, positive tilt test, or hypertension. The injury rates were 25.7% (95% CI: 19.1-32.8%) in studies with younger patients (mean age ≤50 years, n = 1803) and 43.4% (95% CI: 34.9-52.3%) in studies with older patients (P = 0.002). Nine studies reported major injuries; with a weighted mean rate of major injuries of 13.9% (95% CI: 9.5-19.8%).
Conclusion 
Injuries due to syncope are frequent, occurring in 33% of patients with VVS. The risk of major injuries is substantial. Older patients are at higher risk. Clinicians should be aware of the risk of injuries when providing care and advice to patients with VVS.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 07 Mar 2021; epub ahead of print
Jorge JG, Raj SR, Teixeira PS, Teixeira JAC, Sheldon RS
Europace: 07 Mar 2021; epub ahead of print | PMID: 33693816
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Impact:
Abstract

Procedural efficiencies, lesion metrics, and 12-month clinical outcomes for Ablation Index-guided 50 W ablation for atrial fibrillation.

O\'Brien J, Obeidat M, Kozhuharov N, Ding WY, ... Snowdon RL, Gupta D
Aims
The safety of Ablation Index (AI)-guided 50 W ablation for atrial fibrillation (AF) remains uncertain, and mid-term clinical outcomes have not been described. The interplay between AI and its components at 50 W has not been reported.
Methods and results
Eighty-eight consecutive AF patients (44% paroxysmal) underwent AI-guided 50 W ablation. Procedural and 12-month clinical outcomes were compared with 93 consecutive controls (65% paroxysmal) who underwent AI-guided ablation using 35-40 W. Posterior wall isolation (PWI) was performed in 44 (50%) and 23 (25%) patients in the 50 and 35-40 W groups, respectively, P < 0.001. The last 10 patients from each group underwent analysis of individual lesions (n = 1230) to explore relationships between different powers and the AI components. Pulmonary vein isolation was successful in all patients. Posterior wall isolation was successful in 41/44 (93.2%) and 22/23 (95.7%) in the 50 and 35-40 W groups, respectively (P = 0.685). Radiofrequency times (20 vs. 26 min, P < 0.001) and total procedure times (130 vs. 156 min, P = 0.002) were significantly lower in the 50 W group. No complication or steam pop was seen in either group. Twelve-month freedom from arrhythmia was similar (80.2% vs. 82.8%, P = 0.918). A higher proportion of lesions in the 50 W group were associated with impedance drop >7 Ω (54.6% vs. 45.5%, P < 0.001). Excessive ablation (AI >600 anteriorly, >500 posteriorly) was more frequent in the 50 W group (9.7% vs. 4.3%, P < 0.001).
Conclusion
Ablation Index-guided 50 W AF ablation is as safe and effective as lower powers and results in reduced ablation and procedure times. Radiofrequency lesions are more likely to be therapeutic, but there is a higher risk of delivering excessive ablation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 05 Mar 2021; epub ahead of print
O'Brien J, Obeidat M, Kozhuharov N, Ding WY, ... Snowdon RL, Gupta D
Europace: 05 Mar 2021; epub ahead of print | PMID: 33693677
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Impact:
Abstract

Quantitative collagen assessment in right ventricular myectomies from patients with tetralogy of Fallot.

Wülfers EM, Greiner J, Giese M, Madl J, ... Rog-Zielinska EA, Fürniss HE
Aims
Patients with tetralogy of Fallot (TOF) are often affected by right ventricular fibrosis, which has been associated with arrhythmias. This study aimed to assess fibrosis distribution in right ventricular outflow tract (RVOT) myocardium of TOF patients to evaluate the utility of single histology-section analyses, and to explore the possibility of fibrosis quantification in unlabelled tissue by second harmonic generation imaging (SHGI) as an alternative to conventional histology-based assays.
Methods and results
We quantified fibrosis in 11 TOF RVOT samples, using a tailor-made automated image analysis method on Picrosirius red-stained sections. In a subset of samples, histology- and SHGI-based fibrosis quantification approaches were compared. Fibrosis distribution was highly heterogeneous, with significant and comparable variability between and within samples. We found that, on average, 67.8 mm2 of 10 µm thick, histologically processed tissue per patient had to be analysed for accurate fibrosis quantification. SHGI provided data faster and on live tissue, additionally enabling quantification of collagen anisotropy.
Conclusion
Given the high intra-individual heterogeneity, fibrosis quantification should not be conducted on single sections of TOF RVOT myectomies. We provide an analysis algorithm for fibrosis quantification in histological images, which enables the required extended volume analyses in these patients.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 03 Mar 2021; 23:i38-i47
Wülfers EM, Greiner J, Giese M, Madl J, ... Rog-Zielinska EA, Fürniss HE
Europace: 03 Mar 2021; 23:i38-i47 | PMID: 33404047
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Impact:
Abstract

Using machine learning to identify local cellular properties that support re-entrant activation in patient-specific models of atrial fibrillation.

Corrado C, Williams S, Roney C, Plank G, O\'Neill M, Niederer S
Aims
Atrial fibrillation (AF) is sustained by re-entrant activation patterns. Ablation strategies have been proposed that target regions of tissue that may support re-entrant activation patterns. We aimed to characterize the tissue properties associated with regions that tether re-entrant activation patterns in a validated virtual patient cohort.
Methods and results
Atrial fibrillation patient-specific models (seven paroxysmal and three persistent) were generated and validated against local activation time (LAT) measurements during an S1-S2 pacing protocol from the coronary sinus and high right atrium, respectively. Atrial models were stimulated with burst pacing from three locations in the proximity of each pulmonary vein to initiate re-entrant activation patterns. Five atria exhibited sustained activation patterns for at least 80 s. Models with short maximum action potential durations (APDs) were associated with sustained activation. Phase singularities were mapped across the atria sustained activation patterns. Regions with a low maximum conduction velocity (CV) were associated with tethering of phase singularities. A support vector machine (SVM) was trained on maximum local conduction velocity and action potential duration to identify regions that tether phase singularities. The SVM identified regions of tissue that could support tethering with 91% accuracy. This accuracy increased to 95% when the SVM was also trained on surface area.
Conclusion
In a virtual patient cohort, local tissue properties, that can be measured (CV) or estimated (APD; using effective refractory period as a surrogate) clinically, identified regions of tissue that tether phase singularities. Combing CV and APD with atrial surface area further improved the accuracy in identifying regions that tether phase singularities.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 03 Mar 2021; 23:i12-i20
Corrado C, Williams S, Roney C, Plank G, O'Neill M, Niederer S
Europace: 03 Mar 2021; 23:i12-i20 | PMID: 33437987
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Impact:
Abstract

On the nature of delays allowing anatomical re-entry involving the Purkinje network: a simulation study.

Vigmond EJ, Bouyssier J, Bayer J, Haïssaguerre M, Ashikaga H
Aims
Clinical observations suggest that the Purkinje network can be part of anatomical re-entry circuits in monomorphic or polymorphic ventricular arrhythmias. However, significant conduction delay is needed to support anatomical re-entry given the high conduction velocity within the Purkinje network.
Methods and results
We investigated, in computer models, whether damage rendering the Purkinje network as either an active lesion with slow conduction or a passive lesion with no excitable ionic channel, could explain clinical observations. Active lesions had compromised sodium current and a severe reduction in gap junction coupling, while passive lesions remained coupled by gap junctions, but modelled the membrane as a fixed resistance. Both types of tissue could provide significant delays of over 100 ms. Electrograms consistent with those obtained clinically were reproduced. However, passive tissue could not support re-entry as electrotonic coupling across the delay effectively increased the proximal refractory period to an extremely long interval. Active tissue, conversely, could robustly maintain re-entry.
Conclusion
Formation of anatomical re-entry using the Purkinje network is possible through highly reduced gap junctional coupling leading to slowed conduction.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 03 Mar 2021; 23:i71-i79
Vigmond EJ, Bouyssier J, Bayer J, Haïssaguerre M, Ashikaga H
Europace: 03 Mar 2021; 23:i71-i79 | PMID: 33463686
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Impact:
Abstract

Human biventricular electromechanical simulations on the progression of electrocardiographic and mechanical abnormalities in post-myocardial infarction.

Wang ZJ, Santiago A, Zhou X, Wang L, ... Vazquez M, Rodriguez B
Aims
Develop, calibrate and evaluate with clinical data a human electromechanical modelling and simulation framework for multiscale, mechanistic investigations in healthy and post-myocardial infarction (MI) conditions, from ionic to clinical biomarkers.
Methods and results
Human healthy and post-MI electromechanical simulations were conducted with a novel biventricular model, calibrated and evaluated with experimental and clinical data, including torso/biventricular anatomy from clinical magnetic resonance, state-of-the-art human-based membrane kinetics, excitation-contraction and active tension models, and orthotropic electromechanical coupling. Electromechanical remodelling of the infarct/ischaemic region and the border zone were simulated for ischaemic, acute, and chronic states in a fully transmural anterior infarct and a subendocardial anterior infarct. The results were compared with clinical electrocardiogram and left ventricular ejection fraction (LVEF) data at similar states. Healthy model simulations show LVEF 63%, with 11% peak systolic wall thickening, QRS duration and QT interval of 100 ms and 330 ms. LVEF in ischaemic, acute, and chronic post-MI states were 56%, 51%, and 52%, respectively. In linking the three post-MI simulations, it was apparent that elevated resting potential due to hyperkalaemia in the infarcted region led to ST-segment elevation, while a large repolarization gradient corresponded to T-wave inversion. Mechanically, the chronic stiffening of the infarct region had the benefit of improving systolic function by reducing infarct bulging at the expense of reducing diastolic function by inhibiting inflation.
Conclusion
Our human-based multiscale modelling and simulation framework enables mechanistic investigations into patho-physiological electrophysiological and mechanical behaviour and can serve as testbed to guide the optimization of pharmacological and electrical therapies.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 03 Mar 2021; 23:i143-i152
Wang ZJ, Santiago A, Zhou X, Wang L, ... Vazquez M, Rodriguez B
Europace: 03 Mar 2021; 23:i143-i152 | PMID: 33751088
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Impact:
Abstract

Incidence, prevalence, and trajectories of repetitive conduction patterns in human atrial fibrillation.

van Rosmalen F, Maesen B, van Hunnik A, Hermans BJM, ... Schotten U, Zeemering S
Aims
Repetitive conduction patterns in atrial fibrillation (AF) may reflect anatomical structures harbouring preferential conduction paths and indicate the presence of stationary sources for AF. Recently, we demonstrated a novel technique to detect repetitive patterns in high-density contact mapping of AF. As a first step towards repetitive pattern mapping to guide AF ablation, we determined the incidence, prevalence, and trajectories of repetitive conduction patterns in epicardial contact mapping of paroxysmal and persistent AF patients.
Methods and results
A 256-channel mapping array was used to record epicardial left and right AF electrograms in persistent AF (persAF, n = 9) and paroxysmal AF (pAF, n = 11) patients. Intervals containing repetitive conduction patterns were detected using recurrence plots. Activation movies, preferential conduction direction, and average activation sequence were used to characterize and classify conduction patterns. Repetitive patterns were identified in 33/40 recordings. Repetitive patterns were more prevalent in pAF compared with persAF [pAF: median 59%, inter-quartile range (41-72) vs. persAF: 39% (0-51), P < 0.01], larger [pAF: = 1.54 (1.15-1.96) vs. persAF: 1.16 (0.74-1.56) cm2, P < 0.001), and more stable [normalized preferentiality (0-1) pAF: 0.38 (0.25-0.50) vs. persAF: 0.23 (0-0.33), P < 0.01]. Most repetitive patterns were peripheral waves (87%), often with conduction block (69%), while breakthroughs (9%) and re-entries (2%) occurred less frequently.
Conclusion
High-density epicardial contact mapping in AF patients reveals frequent repetitive conduction patterns. In persistent AF patients, repetitive patterns were less frequent, smaller, and more variable than in paroxysmal AF patients. Future research should elucidate whether these patterns can help in finding AF ablation targets.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 03 Mar 2021; 23:i123-i132
van Rosmalen F, Maesen B, van Hunnik A, Hermans BJM, ... Schotten U, Zeemering S
Europace: 03 Mar 2021; 23:i123-i132 | PMID: 33751087
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Impact:
Abstract

Fully coupled dynamic simulations of bioprosthetic aortic valves based on an embedded strategy for fluid-structure interaction with contact.

Nestola MGC, Zulian P, Gaedke-Merzhäuser L, Krause R
Aims
This work aims at presenting a fully coupled approach for the numerical solution of contact problems between multiple elastic structures immersed in a fluid flow. The key features of the computational model are (i) a fully coupled fluid-structure interaction with contact, (ii) the use of a fibre-reinforced material for the leaflets, (iii) a stent, and (iv) a compliant aortic root.
Methods and results
The computational model takes inspiration from the immersed boundary techniques and allows the numerical simulation of the blood-tissue interaction of bioprosthetic heart valves (BHVs) as well as the contact among the leaflets. First, we present pure mechanical simulations, where blood is neglected, to assess the performance of different material properties and valve designs. Secondly, fully coupled fluid-structure interaction simulations are employed to analyse the combination of haemodynamic and mechanical characteristics. The isotropic leaflet tissue experiences high-stress values compared to the fibre-reinforced material model. Moreover, elongated leaflets show a stress concentration close to the base of the stent. We observe a fully developed flow at the systolic stage of the heartbeat. On the other hand, flow recirculation appears along the aortic wall during diastole.
Conclusion
The presented FSI approach can be used for analysing the mechanical and haemodynamic performance of a BHV. Our study suggests that stresses concentrate in the regions where leaflets are attached to the stent and in the portion of the aortic root where the BHV is placed. The results from this study may inspire new BHV designs that can provide a better stress distribution.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 03 Mar 2021; 23:i96-i104
Nestola MGC, Zulian P, Gaedke-Merzhäuser L, Krause R
Europace: 03 Mar 2021; 23:i96-i104 | PMID: 33751086
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Impact:
Abstract

Synergistic antiarrhythmic effect of inward rectifier current inhibition and pulmonary vein isolation in a 3D computer model for atrial fibrillation.

Gharaviri A, Pezzuto S, Potse M, Conte G, ... Auricchio A, Schotten U
Aims
Recent clinical studies showed that antiarrhythmic drug (AAD) treatment and pulmonary vein isolation (PVI) synergistically reduce atrial fibrillation (AF) recurrences after initially successful ablation. Among newly developed atrial-selective AADs, inhibitors of the G-protein-gated acetylcholine-activated inward rectifier current (IKACh) were shown to effectively suppress AF in an experimental model but have not yet been evaluated clinically. We tested in silico whether inhibition of inward rectifier current or its combination with PVI reduces AF inducibility.
Methods and results
We simulated the effect of inward rectifier current blockade (IK blockade), PVI, and their combination on AF inducibility in a detailed three-dimensional model of the human atria with different degrees of fibrosis. IK blockade was simulated with a 30% reduction of its conductivity. Atrial fibrillation was initiated using incremental pacing applied at 20 different locations, in both atria. IK blockade effectively prevented AF induction in simulations without fibrosis as did PVI in simulations without fibrosis and with moderate fibrosis. Both interventions lost their efficacy in severe fibrosis. The combination of IK blockade and PVI prevented AF in simulations without fibrosis, with moderate fibrosis, and even with severe fibrosis. The combined therapy strongly decreased the number of fibrillation waves, due to a synergistic reduction of wavefront generation rate while the wavefront lifespan remained unchanged.
Conclusion
Newly developed blockers of atrial-specific inward rectifier currents, such as IKAch, might prevent AF occurrences and when combined with PVI effectively supress AF recurrences in human.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 03 Mar 2021; 23:i161-i168
Gharaviri A, Pezzuto S, Potse M, Conte G, ... Auricchio A, Schotten U
Europace: 03 Mar 2021; 23:i161-i168 | PMID: 33751085
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Abstract

Cycle length statistics during human atrial fibrillation reveal refractory properties of the underlying substrate: a combined in silico and clinical test of concept study.

Unger LA, Azzolin L, Nothstein M, Sánchez J, ... Spector P, Loewe A
Aims
The treatment of atrial fibrillation beyond pulmonary vein isolation has remained an unsolved challenge. Targeting regions identified by different substrate mapping approaches for ablation resulted in ambiguous outcomes. With the effective refractory period being a fundamental prerequisite for the maintenance of fibrillatory conduction, this study aims at estimating the effective refractory period with clinically available measurements.
Methods and results
A set of 240 simulations in a spherical model of the left atrium with varying model initialization, combination of cellular refractory properties, and size of a region of lowered effective refractory period was implemented to analyse the capabilities and limitations of cycle length mapping. The minimum observed cycle length and the 25% quantile were compared to the underlying effective refractory period. The density of phase singularities was used as a measure for the complexity of the excitation pattern. Finally, we employed the method in a clinical test of concept including five patients. Areas of lowered effective refractory period could be distinguished from their surroundings in simulated scenarios with successfully induced multi-wavelet re-entry. Larger areas and higher gradients in effective refractory period as well as complex activation patterns favour the method. The 25% quantile of cycle lengths in patients with persistent atrial fibrillation was found to range from 85 to 190 ms.
Conclusion
Cycle length mapping is capable of highlighting regions of pathologic refractory properties. In combination with complementary substrate mapping approaches, the method fosters confidence to enhance the treatment of atrial fibrillation beyond pulmonary vein isolation particularly in patients with complex activation patterns.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 03 Mar 2021; 23:i133-i142
Unger LA, Azzolin L, Nothstein M, Sánchez J, ... Spector P, Loewe A
Europace: 03 Mar 2021; 23:i133-i142 | PMID: 33751084
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Impact:
Abstract

Efficient identification of scars using heterogeneous model hierarchies.

Chegini F, Kopaničáková A, Krause R, Weiser M
Aims
Detection and quantification of myocardial scars are helpful for diagnosis of heart diseases and for personalized simulation models. Scar tissue is generally characterized by a different conduction of excitation. We aim at estimating conductivity-related parameters from endocardial mapping data. Solving this inverse problem requires computationally expensive monodomain simulations on fine discretizations. We aim at accelerating the estimation by combining electrophysiology models of different complexity.
Methods and results
Distributed parameter estimation is performed by minimizing the misfit between simulated and measured electrical activity on the endocardial surface, subject to the monodomain model and regularization. We formulate this optimization problem, including the modelling of scar tissue and different regularizations, and design an efficient solver. We consider grid hierarchies and monodomain-eikonal model hierarchies in a recursive multilevel trust-region method. With numerical examples, efficiency and estimation quality, depending on the data, are investigated. The multilevel solver is significantly faster than a comparable single level solver. Endocardial mapping data of realistic density appears to be sufficient to provide quantitatively reasonable estimates of location, size, and shape of scars close to the endocardial surface.
Conclusion
In several situations, scar reconstruction based on eikonal and monodomain models differ significantly, suggesting the use of the more involved monodomain model for this purpose. Eikonal models can accelerate the computations considerably, enabling the use of complex electrophysiology models for estimating myocardial scars from endocardial mapping data.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 03 Mar 2021; 23:i113-i122
Chegini F, Kopaničáková A, Krause R, Weiser M
Europace: 03 Mar 2021; 23:i113-i122 | PMID: 33751083
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Impact:
Abstract

Simulation of diffuse and stringy fibrosis in a bilayer interconnected cable model of the left atrium.

Saliani A, Irakoze É, Jacquemet V
Aims
The aim of this study is to design a computer model of the left atrium for investigating fibre-orientation-dependent microstructure such as stringy fibrosis.
Methods and results
We developed an approach for automatic construction of bilayer interconnected cable models from left atrial geometry and epi- and endocardial fibre orientation. The model consisted of two layers (epi- and endocardium) of longitudinal and transverse cables intertwined-like fabric threads, with a spatial discretization of 100 µm. Model validation was performed by comparison with cubic volumetric models in normal conditions. Then, diffuse (n = 2904), stringy (n = 3600), and mixed fibrosis patterns (n = 6840) were randomly generated by uncoupling longitudinal and transverse connections in the interconnected cable model. Fibrosis density was varied from 0% to 40% and mean stringy obstacle length from 0.1 to 2 mm. Total activation time, apparent anisotropy ratio, and local activation time jitter were computed during normal rhythm in each pattern. Non-linear regression formulas were identified for expressing measured propagation parameters as a function of fibrosis density and obstacle length (stringy and mixed patterns). Longer obstacles (even below tissue space constant) were independently associated with prolonged activation times, increased anisotropy, and local fluctuations in activation times. This effect was increased by endo-epicardial dissociation and mitigated when fibrosis was limited to the epicardium.
Conclusion
Interconnected cable models enable the study of microstructure in organ-size models despite limitations in the description of transmural structures.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 03 Mar 2021; 23:i169-i177
Saliani A, Irakoze É, Jacquemet V
Europace: 03 Mar 2021; 23:i169-i177 | PMID: 33751082
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Impact:
Abstract

Electromechanical substrate characterization in arrhythmogenic cardiomyopathy using imaging-based patient-specific computer simulations.

van Osta N, Kirkels F, Lyon A, Koopsen T, ... Delhaas T, Lumens J
Aims
Arrhythmogenic cardiomyopathy (AC) is an inherited cardiac disease, characterized by life-threatening ventricular arrhythmias and progressive cardiac dysfunction. The aim of this study is to use computer simulations to non-invasively estimate the individual patient\'s myocardial tissue substrates underlying regional right ventricular (RV) deformation abnormalities in a cohort of AC mutation carriers.
Methods and results
In 68 AC mutation carriers and 20 control subjects, regional longitudinal deformation patterns of the RV free wall (RVfw), interventricular septum (IVS), and left ventricular free wall (LVfw) were obtained using speckle-tracking echocardiography. We developed and used a patient-specific parameter estimation protocol based on the multi-scale CircAdapt cardiovascular system model to create virtual AC subjects. Using the individual\'s deformation data as model input, this protocol automatically estimated regional RVfw and global IVS and LVfw tissue properties. The computational model was able to reproduce clinically measured regional deformation patterns for all subjects, with highly reproducible parameter estimations. Simulations revealed that regional RVfw heterogeneity of both contractile function and compliance were increased in subjects with clinically advanced disease compared to mutation carriers without clinically established disease (17 ± 13% vs. 8 ± 4%, P = 0.01 and 18 ± 11% vs. 10 ± 7%, P < 0.01, respectively). No significant difference in activation delay was found.
Conclusion
Regional RV deformation abnormalities in AC mutation carriers were related to reduced regional contractile function and tissue compliance. In clinically advanced disease stages, a characteristic apex-to-base heterogeneity of tissue abnormalities was present in the majority of the subjects, with most pronounced disease in the basal region of the RVfw.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 03 Mar 2021; 23:i153-i160
van Osta N, Kirkels F, Lyon A, Koopsen T, ... Delhaas T, Lumens J
Europace: 03 Mar 2021; 23:i153-i160 | PMID: 33751081
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Abstract

Exploring the cause of conduction delays in patients with repaired Tetralogy of Fallot.

Verzaal NJ, Massé S, Downar E, Nanthakumar K, Delhaas T, Prinzen FW
Aims
Cardiac dyssynchrony in patients with repaired Tetralogy of Fallot (rToF) has been attributed to right bundle branch block (RBBB), fibrosis and/or the patches that are inserted during repair surgery. We aimed to investigate the basis of abnormal activation in rToF patients by mapping the electrical activation sequence during sinus rhythm (SR) and right ventricular (RV) pacing.
Methods and results
A total of 17 patients were studied [13 with rToF, 2 with left bundle branch block (LBBB), and 2 without RBBB or LBBB (non-BBB)] during medically indicated cardiac surgery. During SR and RV pacing, measurements were performed using 112-electrode RV endocardial balloons (rToF only) and biventricular epicardial sock arrays (four of the rToF and all non-rToF patients). During SR, functional lines of block occurred in five rToF patients, while RV pacing caused functional blocks in four rToF patients. The line of block persisted during both SR and RV pacing in only 2 out of 13 rToF patients. Compared to SR, RV pacing increased dispersion of septal activation, but not dispersion of endocardial and epicardial activation of the RV free wall. During pacing, RV and left ventricular activation dispersion in rToF patients were comparable to that of the non-rToF patients.
Conclusion
The results of the present study indicate that the delayed activation in the right ventricle of rToF patients is predominantly due to block(s) in the Purkinje system and that conduction in RV tissue is fairly normal.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 03 Mar 2021; 23:i105-i112
Verzaal NJ, Massé S, Downar E, Nanthakumar K, Delhaas T, Prinzen FW
Europace: 03 Mar 2021; 23:i105-i112 | PMID: 33751080
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Impact:
Abstract

Atlas-based methods for efficient characterization of patient-specific ventricular activation patterns.

Vincent KP, Forsch N, Govil S, Joblon JM, ... Perry JC, McCulloch AD
Aims
Ventricular activation patterns can aid clinical decision-making directly by providing spatial information on cardiac electrical activation or indirectly through derived clinical indices. The aim of this work was to derive an atlas of the major modes of variation of ventricular activation from model-predicted 3D bi-ventricular activation time distributions and to relate these modes to corresponding vectorcardiograms (VCGs). We investigated how the resulting dimensionality reduction can improve and accelerate the estimation of activation patterns from surface electrogram measurements.
Methods and results
Atlases of activation time (AT) and VCGs were derived using principal component analysis on a dataset of simulated electrophysiology simulations computed on eight patient-specific bi-ventricular geometries. The atlases provided significant dimensionality reduction, and the modes of variation in the two atlases described similar features. Utility of the atlases was assessed by resolving clinical waveforms against them and the VCG atlas was able to accurately reconstruct the patient VCGs with fewer than 10 modes. A sensitivity analysis between the two atlases was performed by calculating a compact Jacobian. Finally, VCGs generated by varying AT atlas modes were compared with clinical VCGs to estimate patient-specific activation maps, and the resulting errors between the clinical and atlas-based VCGs were less than those from more computationally expensive method.
Conclusion
Atlases of activation and VCGs represent a new method of identifying and relating the features of these high-dimensional signals that capture the major sources of variation between patients and may aid in identifying novel clinical indices of arrhythmia risk or therapeutic outcome.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 03 Mar 2021; 23:i88-i95
Vincent KP, Forsch N, Govil S, Joblon JM, ... Perry JC, McCulloch AD
Europace: 03 Mar 2021; 23:i88-i95 | PMID: 33751079
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Impact:
Abstract

Automatic reconstruction of the left atrium activation from sparse intracardiac contact recordings by inverse estimate of fibre structure and anisotropic conduction in a patient-specific model.

Lubrecht JM, Grandits T, Gharaviri A, Schotten U, ... Conte G, Pezzuto S
Aims
Electric conduction in the atria is direction-dependent, being faster in fibre direction, and possibly heterogeneous due to structural remodelling. Intracardiac recordings of atrial activation may convey such information, but only with high-quality data. The aim of this study was to apply a patient-specific approach to enable such assessment even when data are scarce, noisy, and incomplete.
Methods and results
Contact intracardiac recordings in the left atrium from nine patients who underwent ablation therapy were collected before pulmonary veins isolation and retrospectively included in the study. The Personalized Inverse Eikonal Model from cardiac Electro-Anatomical Maps (PIEMAP), previously developed, has been used to reconstruct the conductivity tensor from sparse recordings of the activation. Regional fibre direction and conduction velocity were estimated from the fitted conductivity tensor and extensively cross-validated by clustered and sparse data removal. Electrical conductivity was successfully reconstructed in all patients. Cross-validation with respect to the measurements was excellent in seven patients (Pearson correlation r > 0.93) and modest in two patients (r = 0.62 and r = 0.74). Bland-Altman analysis showed a neglectable bias with respect to the measurements and the limit-of-agreement at -22.2 and 23.0 ms. Conduction velocity in the fibre direction was 82 ± 25 cm/s, whereas cross-fibre velocity was 46 ± 7 cm/s. Anisotropic ratio was 1.91±0.16. No significant inter-patient variability was observed. Personalized Inverse Eikonal model from cardiac Electro-Anatomical Maps correctly predicted activation times in late regions in all patients (r = 0.88) and was robust to a sparser dataset (r = 0.95).
Conclusion
Personalized Inverse Eikonal model from cardiac Electro-Anatomical Maps offers a novel approach to extrapolate the activation in unmapped regions and to assess conduction properties of the atria. It could be seamlessly integrated into existing electro-anatomic mapping systems. Personalized Inverse Eikonal model from cardiac Electro-Anatomical Maps also enables personalization of cardiac electrophysiology models.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 03 Mar 2021; 23:i63-i70
Lubrecht JM, Grandits T, Gharaviri A, Schotten U, ... Conte G, Pezzuto S
Europace: 03 Mar 2021; 23:i63-i70 | PMID: 33751078
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Impact:
Abstract

Novel CineECG enables anatomical 3D localization and classification of bundle branch blocks.

Boonstra MJ, Hilderink BN, Locati ET, Asselbergs FW, Loh P, van Dam PM
Aims
Ventricular conduction disorders can induce arrhythmias and impair cardiac function. Bundle branch blocks (BBBs) are diagnosed by 12-lead electrocardiogram (ECG), but discrimination between BBBs and normal tracings can be challenging. CineECG computes the temporo-spatial trajectory of activation waveforms in a 3D heart model from 12-lead ECGs. Recently, in Brugada patients, CineECG has localized the terminal components of ventricular depolarization to right ventricle outflow tract (RVOT), coincident with arrhythmogenic substrate localization detected by epicardial electro-anatomical maps. This abnormality was not found in normal or right BBB (RBBB) patients. This study aimed at exploring whether CineECG can improve the discrimination between left BBB (LBBB)/RBBB, and incomplete RBBB (iRBBB).
Methods and results
We utilized 500 12-lead ECGs from the online Physionet-XL-PTB-Diagnostic ECG Database with a certified ECG diagnosis. The mean temporo-spatial isochrone trajectory was calculated and projected into the anatomical 3D heart model. We established five CineECG classes: \'Normal\', \'iRBBB\', \'RBBB\', \'LBBB\', and \'Undetermined\', to which each tracing was allocated. We determined the accuracy of CineECG classification with the gold standard diagnosis. A total of 391 ECGs were analysed (9 ECGs were excluded for noise) and 240/266 were correctly classified as \'normal\', 14/17 as \'iRBBB\', 55/55 as \'RBBB\', 51/51 as \'LBBB\', and 31 as \'undetermined\'. The terminal mean temporal spatial isochrone contained most information about the BBB localization.
Conclusion
CineECG provided the anatomical localization of different BBBs and accurately differentiated between normal, LBBB and RBBB, and iRBBB. CineECG may aid clinical diagnostic work-up, potentially contributing to the difficult discrimination between normal, iRBBB, and Brugada patients.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 03 Mar 2021; 23:i80-i87
Boonstra MJ, Hilderink BN, Locati ET, Asselbergs FW, Loh P, van Dam PM
Europace: 03 Mar 2021; 23:i80-i87 | PMID: 33751077
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Impact:
Abstract

Pulmonary vein isolation in a real-world population does not influence QTc interval.

Hermans BJM, Zink MD, van Rosmalen F, Crijns HJGM, ... Schotten U, Delhaas T
Aims
We aimed to examine whether routine pulmonary vein isolation (PVI) induces significant ventricular repolarization changes as suggested earlier.
Methods and results
Five-minute electrocardiograms were recorded at hospital\'s admission (T-1d), 1 day after the PVI-procedure (T+1d) and at 3 months post-procedure (T+3m) from a registry of consecutive atrial fibrillation (AF) patients scheduled for routine PVI with different PVI modalities (radiofrequency, cryo-ablation, and hybrid). Only patients who were in sinus rhythm at all three recordings (n = 117) were included. QT-intervals and QT-dispersion were evaluated with custom-made software and QTc was calculated using Bazett\'s, Fridericia\'s, Framingham\'s, and Hodges\' formulas. Both QT- and RR-intervals were significantly shorter at T+1d (399 ± 37 and 870 ± 141 ms) and T+3m (407 ± 36 and 950 ± 140 ms) compared with baseline (417 ± 36 and 1025 ± 164 ms). There was no statistically significant within-subject difference in QTc Fridericia (T-1d 416 ± 28 ms, T+1d 419 ± 33 ms, and T+3m 414 ± 25 ms) and QT-dispersion (T-1d 18 ± 12 ms, T+1d 21 ± 19 ms, and T+3m 17 ± 12 ms) between the recordings. A multiple linear regression model with age, sex, AF type, ablation technique, first/re-do ablation, and AF recurrence to predict the change in QTc at T+3m with respect to QTc at T-1d did not reach significance which indicates that the change in QTc does not differ between all subgroups (age, sex, AF type, ablation technique, first/re-do ablation, and AF recurrence).
Conclusion
Based on our data a routine PVI does not result in a prolongation of QTc in a real-world population. These findings, therefore, suggest that there is no need to intensify post-PVI QT-interval monitoring.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 03 Mar 2021; 23:i48-i54
Hermans BJM, Zink MD, van Rosmalen F, Crijns HJGM, ... Schotten U, Delhaas T
Europace: 03 Mar 2021; 23:i48-i54 | PMID: 33751076
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Impact:
Abstract

Evolution of P-wave indices during long-term follow-up as markers of atrial substrate progression in arrhythmogenic right ventricular cardiomyopathy.

Baturova MA, Svensson A, Aneq MÅ, Svendsen JH, ... Carlson J, Platonov PG
Aims
Patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) have increased prevalence of atrial arrhythmias indicating atrial involvement in the disease. We aimed to assess the long-term evolution of P-wave indices as electrocardiographic (ECG) markers of atrial substrate during ARVC progression.
Methods and results
We included 100 patients with a definite ARVC diagnosis according to 2010 Task Force criteria [34% females, median age 41 (inter-quartile range 30-55) years]. All available sinus rhythm ECGs (n = 1504) were extracted from the regional electronic ECG databases and automatically processed using Glasgow algorithm. P-wave duration, P-wave area, P-wave frontal axis, and prevalence of abnormal P terminal force in lead V1 (aPTF-V1) were assessed and compared at ARVC diagnosis, 10 years before and up to 15 years after diagnosis.Prior to ARVC diagnosis, none of the P-wave indices differed significantly from the data at ARVC diagnosis. After ascertainment of ARVC diagnosis, P-wave area in lead V1 decreased from -1 to -30 µV ms at 5 years (P = 0.002). P-wave area in lead V2 decreased from 82 µV ms at ARVC diagnosis to 42 µV ms 10 years after ARVC diagnosis (P = 0.006). The prevalence of aPTF-V1 increased from 5% at ARVC diagnosis to 18% by the 15th year of follow-up (P = 0.004). P-wave duration and frontal axis did not change during disease progression.
Conclusion
Initial ARVC progression was associated with P-wave flattening in right precordial leads and in later disease stages an increased prevalence of aPTF-V1 was seen.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 03 Mar 2021; 23:i29-i37
Baturova MA, Svensson A, Aneq MÅ, Svendsen JH, ... Carlson J, Platonov PG
Europace: 03 Mar 2021; 23:i29-i37 | PMID: 33751075
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Impact:
Abstract

Characterizing the arrhythmogenic substrate in personalized models of atrial fibrillation: sensitivity to mesh resolution and pacing protocol in AF models.

Boyle PM, Ochs AR, Ali RL, Paliwal N, Trayanova NA
Aims
Computationally guided persistent atrial fibrillation (PsAF) ablation has emerged as an alternative to conventional treatment planning. To make this approach scalable, computational cost and the time required to conduct simulations must be minimized while maintaining predictive accuracy. Here, we assess the sensitivity of the process to finite-element mesh resolution. We also compare methods for pacing site distribution used to evaluate inducibility arrhythmia sustained by re-entrant drivers (RDs).
Methods and results
Simulations were conducted in low- and high-resolution models (average edge lengths: 400/350 µm) reconstructed from PsAF patients\' late gadolinium enhancement magnetic resonance imaging scans. Pacing was simulated from 80 sites to assess RD inducibility. When pacing from the same site led to different outcomes in low-/high-resolution models, we characterized divergence dynamics by analysing dissimilarity index over time. Pacing site selection schemes prioritizing even spatial distribution and proximity to fibrotic tissue were evaluated. There were no RD sites observed in low-resolution models but not high-resolution models, or vice versa. Dissimilarity index analysis suggested that differences in simulation outcome arising from differences in discretization were the result of isolated conduction block incidents in one model but not the other; this never led to RD sites unique to one mesh resolution. Pacing site selection based on fibrosis proximity led to the best observed trade-off between number of stimulation locations and predictive accuracy.
Conclusion
Simulations conducted in meshes with 400 µm average edge length and ∼40 pacing sites proximal to fibrosis are sufficient to reveal the most comprehensive possible list of RD sites, given feasibility constraints.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 03 Mar 2021; 23:i3-i11
Boyle PM, Ochs AR, Ali RL, Paliwal N, Trayanova NA
Europace: 03 Mar 2021; 23:i3-i11 | PMID: 33751074
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Impact:
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