<div><h4>Incidence and Predictors of Stroke and Silent Cerebral Embolism Following Very High-Power Short-Duration Atrial Fibrillation Ablation.</h4><i>Boga M, Suhai FI, Orbán G, Salló Z, ... Gellér L, Szegedi N</i><br /><b>Background:</b><br/>and aims</b><br />Cerebral thromboembolism is a dreaded complication of pulmonary vein isolation (PVI) for atrial fibrillation (AF); its surrogate, silent cerebral embolism (SCE) can be detected by diffusion-weighted brain magnetic resonance imaging (bMRI). Initial investigations have raised a concern that very high-power, short-duration (vHPSD; 90W/4 sec) temperature-controlled PVI with the QDOT Micro catheter may be associated with a higher incidence of SCE compared to low-power long-duration ablation (LPLD). We aimed to assess the incidence of procedural complications of vHPSD PVI with an emphasis on cerebral safety.<br /><b>Methods</b><br />We enrolled 328 consecutive patients undergoing their PVI procedure using vHPSD. A subgroup of 61 consecutive patients underwent diffusion-weighted bMRI within 24 hours of the procedure, and incidence and predictors of SCE were studied.<br /><b>Results</b><br />The mean procedure time and left atrial dwell time for the overall cohort was 69.6 ± 24.1 min and 46.5 ± 21.5 min, respectively. First-pass isolation was achieved in 82%. No stroke or transient ischemic attack occurred. SCE was identified in 5 out of 61 patients (8.2%). SCE following procedures was significantly associated with lower baseline generator-impedance (105.8 vs 112.6 Ω, p < 0.0001), and with intermittent loss of catheter-tissue contact during ablation (14.1% vs 6.1%, p < 0.0001).<br /><b>Conclusion</b><br />vHPSD PVI is a safe technique with an excellent acute success rate. SCE incidence in our cohort was below the previously reported range, with no clinically overt cerebral complications. Lower baseline generator-impedance and loss of contact during ablation may contribute to a higher risk of SCEs.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 01 Nov 2023; epub ahead of print</small></div>

<div><h4>Characterization of unipolar electrogram morphology: a novel tool for quantifying conduction inhomogeneity.</h4><i>Ye Z, van Schie MS, Pool L, Heida A, ... Brundel BJJM, de Groot NMS</i><br /><b>Aims</b><br />Areas of conduction inhomogeneity (CI) during sinus rhythm (SR) may facilitate initiation and perpetuation of atrial fibrillation (AF). Currently, no tool is available to quantify the severity of conduction inhomogeneity. Our purpose is to develop and validate a novel tool using unipolar electrograms (EGMs) only to quantify the severity of conduction inhomogeneity in the atria.<br /><b>Methods and results</b><br />Epicardial mapping of the right (RA) and left atrium, including Bachmann\'s bundle was performed in 235 patients undergoing coronary artery bypass grafting surgery. CI was defined as the amount of conduction block. EGMs were classified as single-, short- and long double -(LDP) and fractionated potentials (FP), and the fractionation duration (FD) of non-single potentials was measured. The proportion of low-voltage areas (LVA,  < 1 mV) was calculated. Increased CI was associated with decreased potential voltages and increased LVAs, LDPs and FPs. The Electrical Fingerprint Score consisting of RA EGMs features, including LVAs and LDPs, was most accurate in predicting CI severity. The RA Electrical Fingerprint Score demonstrated the highest correlation with the amount of CI in both atria (r = 0.70, p < 0.001).<br /><b>Conclusion</b><br />The Electrical Fingerprint Score is a novel tool to quantify severity of CI using only unipolar EGMs characteristics recorded. This tool can be used to stage the degree of conduction abnormalities without construction of spatial activation patterns, potentially enabling early identification of patients at high risk of post-operative AF or selection of the appropriate ablation approach in addition to pulmonary vein isolation at the EP lab.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 01 Nov 2023; epub ahead of print</small></div>

<div><h4>CMR-derived Myocardial Scar is associated with echocardiographic response and clinical prognosis of LBBAP-CRT.</h4><i>Chen Z, Ma X, Gao Y, Wu S, ... Zhao S, Chen K</i><br /><b>Background:</b><br/>and aims</b><br />Left bundle branch area pacing (LBBAP) is a novel approach for cardiac resynchronization therapy (CRT), but the impact of myocardial substrate on its effect is poorly understood. This study aims to assess the association of cardiac magnetic resonance (CMR) -derived scar burden and the response of CRT via LBBAP.<br /><b>Methods</b><br />Consecutive patients with traditional CRT indications who underwent CMR examination and successful LBBAP-CRT were retrospectively analyzed. CMR late gadolinium enhancement (LGE) was used for scar assessment. Echocardiographic reverse remodeling and composite outcomes (defined as all-cause death or heart failure hospitalization) were evaluated. The echocardiographic response was defined as a ≥ 15% reduction of left ventricular (LV) end systolic volume (LVESV).<br /><b>Results</b><br />Among the 54 patients included, LBBAP-CRT resulted in a 74.1% response rate. The non-responders had higher global, septal, and lateral scar burden (all p < 0.001). Global, septal and lateral scar percentage all predicted echocardiographic response [Area under the curve (AUC): 0.857, 0.864, and 0.822; positive likelihood ratio (+LR): 9.859, 5.594 and 3.059, negative likelihood ratio (-LR): 0.323, 0.233 and 0.175 respectively], which was superior to QRS morphology criteria (Strauss LBBB: AUC: 0.696,  + LR 2.101, -LR 0.389). After a median follow-up time of 20.3 (11.5-38.7) months, higher global, septal, and lateral scar burdens were all predictive of the composite outcome (Hazard ratios: 4.996, 7.019 and 4.741, respectively, p\'s < 0.05).<br /><b>Conclusions</b><br />Lower scar burden was associated with higher response rate of LBBAP-CRT. The pre-procedure CMR scar evaluation provides further useful information to identify potential responders and clinical outcomes.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 31 Oct 2023; epub ahead of print</small></div>

<div><h4>Enhancing the Interpretation of Genetic Observations in KCNQ1 in Unselected Populations: Relevance to Secondary Findings.</h4><i>Novelli V, Faultless T, Cerrone M, Care M, ... Spears D, Gollob MH</i><br /><b>Background:</b><br/>and aims</b><br />Rare variants in the KCNQ1 gene are found in the healthy population to a much greater extent than the prevalence of Long QT Syndrome type 1 (LQTS1). This observation creates challenges in the interpretation of KCNQ1 rare variants that may be identified as secondary findings in whole exome sequencing.This study sought to identify missense variants within sub-domains of the KCNQ1-encoded Kv7.1 potassium channel that would be highly predictive of disease in the context of secondary findings.<br /><b>Methods</b><br />We established a set of KCNQ1 variants reported in over 3700 patients with diagnosed or suspected LQTS sent for clinical genetic testing and compared the domain-specific location of identified variants to those observed in an unselected population of 140.000 individuals.<br /><b>Results</b><br />We identified three regions that showed a significant enrichment of KCNQ1 variants associated with LQTS at an OR >2: the pore region, and the adjacent 5th (S5) and 6th (S6) transmembrane (TM) regions. An additional segment within the carboxyl terminus of Kv7.1, conserved region 2 (CR2), also showed an increased odds ratio of disease association. Furthermore, the TM spanning S5-Pore-S6 region correlated with a significant increase in cardiac events.<br /><b>Conclusions</b><br />Rare missense variants with a clear phenotype of LQTS have a high likelihood to be present within the pore and adjacent TM segments (S5-Pore-S6) and a greater tendency to be present within CR2. This data will enhance interpretation of secondary findings within the KCNQ1 gene. Further, our data support a more severe phenotype in LQTS patients with variants within the S5-Pore-S6 region.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 28 Oct 2023; epub ahead of print</small></div>

<div><h4>Detection of brain lesions after catheter ablation depends on imaging criteria - Insights from AXAFA-AFNET 5 trial.</h4><i>Haeusler KG, Eichner FA, Heuschmann PU, Fiebach JB, ... Di Biase L, Kirchhof P</i><br /><b>Background:</b><br/>and aims</b><br />Left atrial catheter ablation is well-established in patients with symptomatic atrial fibrillation (AF) but associated with risk of embolism to the brain. To assess the impact of diffusion-weighted imaging (DWI) slice thickness on the rate of magnetic resonance imaging (MRI) detected ischemic brain lesions after ablation.<br /><b>Methods</b><br />AXAFA-AFNET 5 trial (NCT02227550) participants underwent MRI using high-resolution (hr) DWI (slice thickness: 2.5-3 mm) and standard DWI (slice thickness: 5-6 mm) within 3-48 hours after ablation.<br /><b>Results</b><br />In 321 patients with analyzable brain MRI (mean age 64 years, 33% female, median CHA2DS2-VASc 2), hrDWI detected at least one acute brain lesion in 84 (26.2%) patients and standard DWI in 60 (18.7%; p < 0.01) patients. hrDWI detected more lesions compared to standard DWI (165 vs. 104; p < 0.01). The degree of agreement for lesion confirmation using hrDWI vs. standard DWI was substantial (κ=0769). Comparing the proportion of DWI-detected lesions, lesion distribution and total lesion volume per patient, there was no difference in the cohort of participants undergoing MRI at 1.5 Tesla (n = 52) vs. 3 Tesla (n = 269).<br /><b>Conclusion</b><br />The pre-specified AXAFA-AFNET 5 sub-analysis revealed significantly increased rates of MRI-detected acute brain lesions using hrDWI instead of standard DWI in AF patients undergoing ablation. In comparison to DWI slice thickness, MRI field strength had a no significant impact in the trial. Comparing the varying rate of ablation-related MRI-detected brain lesions across previous studies have to consider these technical parameters. Future studies should use hrDWI, as feasibility was demonstrated in the multicenter AXAFA-AFNET 5 trial.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 28 Oct 2023; epub ahead of print</small></div>

<div><h4>Outcomes of catheter ablation in high-risk patients with Brugada syndrome refusing an ICD implantation.</h4><i>Li L, Ding L, Zhou L, Wu L, ... Zhang Z, Yao Y</i><br /><b>Aims</b><br />The aim of this study was to investigate the outcomes of catheter ablation (CA) in preventing arrhythmic events among patients with symptomatic Brugada syndrome (BrS) who declined implantable cardioverter-defibrillator (ICD) implantation.<br /><b>Methods and results</b><br />A total of 40 patients with symptomatic BrS were included in the study, of which 18 patients refused ICD implantation and underwent CA, while 22 patients received ICD implantation. The study employed substrate modification (including endocardial and epicardial approaches) and VF-triggering premature ventricular contraction (PVC) ablation strategies. The primary outcomes were a composite endpoint consisting of episodes of ventricular fibrillation (VF) and sudden cardiac death during the follow-up period. The study population had a mean age of 43.8 ± 9.6 years, with 36 (90.0%) of them being male. All patients exhibited the typical type 1 BrS electrocardiogram pattern, and 16 (40.0%) were carriers of an SCN5A mutation. The Shanghai risk scores were comparable between the CA and ICD groups (7.05 ± 0.80 vs. 6.71 ± 0.86, P = 0.351). VF-triggering PVCs were ablated in 3 patients (16.7%), while VF substrates were ablated in 15 patients (83.3%). Epicardial ablation was performed in 12 patients (66.7%). During a median follow-up of 46.2 (17.5-73.7) months, the primary outcomes occurred more frequently in the ICD group compared to the CA group (5.6% vs. 54.5%, Log-rank P = 0.012).<br /><b>Conclusion</b><br />CA is an effective alternative therapy for improving arrhythmic outcomes in patients with symptomatic BrS who decline ICD implantation. Our findings support the consideration of CA as an alternative treatment option in this population.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 27 Oct 2023; epub ahead of print</small></div>

<div><h4>Prognostic Value of Chronic Kidney Disease in Patients Undergoing Left Atrial Appendage Occlusion.</h4><i>Della Rocca DG, Magnocavallo M, Van Niekerk CJ, Gilhofer T, ... Gibson D, Natale A</i><br /><b>Background:</b><br/>and aims</b><br />Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist and share an increased risk of thromboembolism (TE). CKD concomitantly predisposes towards a pro-haemorrhagic state.Our aim was to evaluate the prognostic value of CKD in patients undergoing percutaneous left atrial appendage occlusion (LAAO).<br /><b>Methods</b><br />2124 consecutive AF patients undergoing LAAO were categorized into CKD stage 1+2 (n=1089), CKD stage 3 (n=796), CKD stage 4 (n=170), CKD stage 5 (n=69) based on the estimated glomerular filtration rate at baseline. The primary endpoint included cardiovascular (CV) mortality, TE, and major bleeding. The expected annual TE and major bleeding risks were estimated based on the CHA2DS2-VASc and HAS-BLED scores.<br /><b>Results</b><br />A non-significant higher incidence of major peri-procedural adverse events (1.7% vs. 2.3% vs. 4.1% vs. 4.3%) was observed with worsening CKD (p=0.14). The mean follow-up period was 13 ± 7 months [2226 patient-years]. In comparison to CKD stage 1+2 as a reference, the incidence of the primary endpoint was significantly higher in CKD stage 3 (log-rank p-value= 0.04), CKD stage 4 (log-rank p-value= 0.01), and CKD stage 5 (log-rank p-value= 0.001). LAAO led to a TE risk reduction (RR) of 72%, 66%, 62%, and 41% in each group. The relative RR of major bleeding was 58%, 44%, 51%, and 52%, respectively.<br /><b>Conclusion</b><br />Patients with moderate-to-severe CKD had a higher incidence of the primary composite endpoint. The relative RR in the incidence of TE and major bleeding was consistent across CKD groups.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 27 Oct 2023; epub ahead of print</small></div>

<div><h4>Comparison of non-laser and laser transvenous lead extraction: a systematic review and meta-analysis.</h4><i>Akhtar Z, Kontogiannis C, Georgiopoulos G, Starck C, ... Sohal M, Gallagher MM</i><br /><b>Background</b><br />Transvenous lead extraction (TLE) is performed using non-laser and laser techniques with overall high efficacy and safety. Variation in outcomes between the two approaches does exist with limited comparative evidence in the literature.<br /><b>Aim</b><br />We sought to compare non-laser and laser TLE in a meta-analysis.<br /><b>Methods</b><br />We searched Medline, Embase, Scopus, ClinicalTrials.gov and CENTRAL databases for TLE studies published between 1991-2021. From the included 68 studies, safety and efficacy data was carefully evaluated and extracted. Aggregated cases of outcomes were used to calculate odds ratio (OR) and pooled rates were synthesised from eligible studies, to compare non-laser and laser techniques. Subgroup comparison of rotational tool and laser extraction was also performed.<br /><b>Results</b><br />Non-laser in comparison to laser had lower procedural mortality (pooled rate 0% vs 0.1%, p < 0.01), major complications (pooled rate 0.7% vs 1.7%, p < 0.01) and superior vena cava (SVC) injury (pooled rate 0% vs 0.5%, p < 0.001), with higher complete success (pooled rate 96.5% vs 93.8%, p < 0.01). Non-laser comparatively to laser was more likely to achieve clinical (OR 2.16 [1.77-2.63], p < 0.01) and complete (OR 1.87 [1.69-2.08], p < 0.01) success, with a lower procedural mortality risk (OR 1.6 [1.02-2.5], p < 0.05). In the subgroup analysis, rotational tool compared to laser achieved greater complete success (pooled rate 97.4% vs 95%, p < 0.01) with lower SVC injury (pooled rate 0% vs 0.7%, p < 0.01).<br /><b>Conclusion</b><br />Non-laser TLE is associated with a better safety and efficacy profile when compared to laser methods. There is a greater risk of SVC injury associated with laser sheath extraction.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 26 Oct 2023; epub ahead of print</small></div>

<div><h4>Optimal Interlesion Distance for 90- and 50-Watt Radiofrequency Applications with low Ablation Index Values: Experimental Findings in a Chronic Ovine Model.</h4><i>Bortone AA, Ramirez FD, Constantin M, Bortone C, ... Bialas P, Limite LR</i><br /><b>Aims</b><br />The optimal interlesion distance (ILD) for 90 and 50W radiofrequency applications with low ablation index (AI) values in the atria has not been established. Excessive ILDs can predispose to interlesion gaps whereas restrictive ILDs can predispose to procedural complications.The present study sought, therefore, to experimentally determine the optimal ILD for 90W-4 sec and 50W applications with low AI values to optimize catheter ablation outcomes in humans.<br /><b>Methods and results</b><br />Posterior intercaval lines were created in 8 adult sheep using CARTO and the QDOT-MICRO catheter in a temperature-controlled mode. In 4 animals the lines were created with 50W applications; a target AI value ≥350; and ILDs of 6, 5, 4 and 3 mm, respectively. In the other 4 animals the lines were created with 90W-4 sec applications and ILDs of 6, 5, 4 and 3 mm, respectively. Activation maps were created immediately after ablation and at 21 days to assess linear block prior to gross and histological analyses.All 8 lines appeared transmural and continuous on histology. However, for 50W only applications with an ILD of 3 mm resulted in durable linear electrical block, whereas for 90W applications only the lines with ILDs of 4 and 3 mm were blocked. No complications were detected during ablation procedures but all power and ILD combinations except 50W-6 mm resulted in asymptomatic shallow lung lesions.<br /><b>Conclusion</b><br />In the intercaval region in sheep, for 50W applications with an AI value of ∼370 the optimal ILD is 3 mm, whereas for 90W-4 sec applications the optimal ILD is 3-4 mm.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 18 Oct 2023; epub ahead of print</small></div>

<div><h4>Lifetime exercise dose and ventricular arrhythmias in patients with mitral valve prolapse.</h4><i>Five CK, Hasselberg NE, Aaserud LT, Castrini AI, ... Aabel EW, Haugaa KH</i><br /><b>Background:</b><br/>and aims</b><br />Patients with mitral valve prolapse (MVP) have high risk of life-threatening ventricular arrhythmias (VA). Data on the impact of exercise on arrhythmic risk in these patients is lacking. We explored whether lifetime exercise dose was associated with severe VA and with established risk factors in patients with MVP. Furthermore, we explored the circumstances at the VA event.<br /><b>Methods</b><br />In this retrospective cohort study, we included patients with MVP and assessed lifetime exercise dose as metabolic equivalents of task (MET)hours/week. Severe VA was defined as sustained ventricular tachycardia or fibrillation, aborted cardiac arrest, and appropriate shock by a primary preventive ICD.<br /><b>Results</b><br />We included 136 MVP patients (48 years [IQR 35-59], 61% female) and 17 (13%) had previous severe VA. The lifetime exercise dose did not differ in patients with and without severe VA (17MET hours/week [IQR 9-27] vs. 14MET hours/week [IQR 6-31], p = 0.34). Lifetime exercise dose >9.6MET hours/week was a borderline significant marker for severe VA (OR 3.38, 95% CI 0.92-12.40, p = 0.07), while not when adjusted for age (OR 2.63, 95% CI 0.66-10.56, p = 0.17). VA events occurred most frequently during wakeful rest (53%), followed by exercise (29%) and sleep (12%).<br /><b>Conclusion</b><br />We found no clear association between moderate lifetime exercise dose and severe VA in patients with MVP. We cannot exclude an upper threshold for safe levels of exercise. Further studies are needed to explore exercise and risk of severe VA.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 18 Oct 2023; epub ahead of print</small></div>

<div><h4>Use of a taurolidine containing antimicrobial wash to reduce cardiac implantable electronic device infection.</h4><i>Borov S, Baldauf B, Henke J, Pavacci H, ... Vonthein R, Bonnemeier H</i><br /><b>Aims</b><br />TauroPace (TauroPharm, Bravaria Germany), a taurolidine solution for combating cardiac implantable electronic device (CIED) infection, was compared to a historical control of 3% hydrogen peroxide (H2O2) in a prospective observational study.<br /><b>Methods</b><br />The device pocket was irrigated and all hardware accessible within (leads, suture sleeves, pulse generator) was wiped with H2O2, TauroPace or taurolidine in a galenic formulation during any invasive CIED procedures at the authors\' institute. Only CIED procedures covered by TauroPace or H-2O2 from 01/01/2017 to 28/02/2022 were included for analysis. Patients who underwent >1 procedure were censored for the last treatment group and reassigned at the next procedure. The primary end point was major CIED infection within 3 months. The secondary end points were CIED infection beyond 3 months, adverse events potentially related to the antimicrobial solutions, CIED system, procedure, and death, till the end of follow-up.<br /><b>Results</b><br />TauroPace covered 654 procedures on 631 patients, and H2O2 covered 551 procedures on 532 patients. The TauroPace group had more host risk factors for infection than the H2O2 group (p=0.0058), but similar device and procedure specific risk factors (p=0.17). CIED infection occurred in 0/654 (0%) of the TauroPace group and 6/551 (1.1%) of the H2O2 group (p=0.0075). Death occurred in 23/654 (3.5%) of the TauroPace group and 14/551 (2.5%) of the H2O2 group (p=0.33). Non-infection related adverse events were rarer in the TauroPace (3.8%) than the H2O2 (6.0%) group (p=0.0802).<br /><b>Conclusions</b><br />TauroPace is as safe as but more effective than H2O2 in reducing CIED infection. (ClinicalTrials.gov Identifier: NCT05576194).<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 13 Oct 2023; epub ahead of print</small></div>

<div><h4>An Unmet Need: Arrhythmia Detection by Implantable Loop Recorder in the Systemic Right Ventricle.</h4><i>Kakarla J, Crossland DS, Murray S, Adhvaryu K, ... Seller N, Coats L</i><br /><b>Background:</b><br/>and aims</b><br />Patients with systemic right ventricles are at high risk of sudden cardiac death. Arrhythmia is a significant risk factor. Routine Holter monitoring is opportunistic with poor adherence. Continuous rhythm monitoring with an implantable loop recorder (ILR) could allow early detection of clinically important arrhythmias.<br /><b>Methods</b><br />ILR implantation was offered to patients with atrial switch repair for transposition of the great arteries. Recordings were made with symptoms or automatically for pauses, significant bradycardia or tachycardia and reviewed by the muti-disciplinary team.<br /><b>Results</b><br />24/36 eligible patients underwent ILR implantation with no complication. 42% had preserved ventricular function, 75% were NYHA functional class I, 88% had low sudden cardiac death risk. 33% had previous IART and none had known conduction disease. 18/24 (75%) patients made 52 recordings (52% automated) over 39.5 months (1.6 -72.5). 32/52 (62%) recordings in 15/24 (63%) of the cohort were clinically significant and included sinus node disease (2 patients), atrio-ventricular block (2 patients), intra-atrial re-entry tachycardia [IART] (7 patients) and IART with sinus node disease or atrio-ventricular block (4 patients). ILR recordings prompted medication change in 11 patients [beta blockers (n=9), anti-coagulation (n=5), stopping anticoagulation (n=1)] and device therapy recommendation in 7 patients [5 pacemakers (3: atrioventricular block), 2 defibrillators]. 2 patients declined intervention; one suffered an arrhythmic death. IART and clinically relevant conduction disease were detected in patients irrespective of sudden cardiac death risk.<br /><b>Conclusion</b><br />Continuous monitoring with an ILR in patients with systemic right ventricle following atrial switch detects clinically relevant arrhythmias that impact decision-making. In this cohort, clinically relevant arrhythmias did not correlate with sudden cardiac death risk.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 10 Oct 2023; epub ahead of print</small></div>

<div><h4>Characteristics of patients with Atrial Fibrillation treated with direct oral anticoagulants and New Insights into inappropriate dosing: Results from the French National PAF Registry.</h4><i>Guenoun M, Cohen S, Villaceque M, Sharareh A, ... Sabouret P, Lellouche N</i><br /><b>Background:</b><br/>and aims</b><br />Since the introduction of direct oral anticoagulant (DOAC) for atrial fibrillation (AF) therapy, inappropriate and/or underdosing of these drugs has been a major clinical challenge. We evaluated the characteristics of AF patients treated with inappropriate and low dose DOACs.<br /><b>Methods</b><br />AF patients treated with inappropriate and low dose DOACs from October 2021 to December 2021 were evaluated from the Prospective French National Registry (PAF).<br /><b>Results</b><br />We evaluated 1890 AF patients receiving DOACs (Apixaban 55%, Dabigatran 7% and Rivaroxaban 38%). Inappropriate dosing was noted in 18% of the population. Patients with appropriate dosing had less comorbidities: younger age (75±10 vs. 82±8 year-old, p<0.0001), reduced chronic renal failure (26% vs. 61%, p<0.0001) and lower CHA2DS2VASc and HASBLED scores (3±2 vs. 4±3, p<0.0001; 2±1 vs. 2±2, p<0.0001), respectively. In multivariate analysis older age (p<0.0001) and a higher CHA2DS2VASc score (p=0.0056) were independently associated with inappropriate DOAC dosing. Among 472 patients (27%) treated with low dose rivaroxaban or apixaban, 46% were inappropriately underdosed. Patients inappropriately underdosed were younger (82.3±8.4 vs. 85.9±5.9 yrs, p<0.0001) with less chronic renal disease (47% vs. 98%, p<0.0001). However, these patients had higher rates of prior haemorrhagic events (18% vs. 10%, p=0.01), clopidogrel use (11% vs. 3%, p=0.0002) and apixaban prescription (74% vs. 50%, p<0.0001).<br /><b>Conclusion</b><br />Within this large registry, DOACs were associated with inappropriate dosing in 18% of cases. Independent predictors of inappropriate dosing were high CHA2DS2VASc scores and older age. Moreover, 46% of patients treated with low dose DOACs were inappropriately underdosed and more frequently occurred with apixaban.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 06 Oct 2023; epub ahead of print</small></div>

<div><h4>Leadless epicardial pacing at the left ventricular apex: an animal study.</h4><i>Backhoff D, Müller MJ, Wilberg Y, Eildermann K, ... Zenker D, Krause U</i><br /><b>Aims</b><br />State-of-the-art pacemaker implantation technique in infants and small children consists of pace/sense electrodes attached to the epicardium and a pulse generator in the abdominal wall with a significant rate of dysfunction during growth, mostly attributable to lead failure. In order to overcome lead-related problems, feasibility of epicardial implantation of a leadless pacemaker at the left ventricular apex in a growing animal model was studied.<br /><b>Methods and results</b><br />Ten lambs (median body weight 26.8 kg) underwent epicardial implantation of a Micra transcatheter pacing system (TPS) pacemaker (Medtronic Inc., Minneapolis, USA). Using a subxyphoid access, the Micra was introduced through a short, thick-walled tube to increase tissue contact and to prevent tilting from the epicardial surface. The Micra\'s proprietary delivery system was firmly pressed against the heart, while the Micra was pushed forward out of the sheath allowing the tines to stick into the left ventricular apical epimyocardium. Pacemakers were programmed to VVI 30/min mode. Pacemaker function and integrity was followed for 4 months after implantation. After implantation, median intrinsic R-wave amplitude was 5 mV [interquartile range (IQR) 2.8-7.5], and median pacing impedance was 2235 Ω (IQR 1725-2500), while the median pacing threshold was 2.13 V (IQR 1.25-2.9) at 0.24 ms. During follow-up, 6/10 animals had a significant increase in pacing threshold with loss of capture at maximum output at 0.24 ms in 2/10 animals. After 4 months, median R-wave amplitude had dropped to 2.25 mV (IQR 1.2-3.6), median pacing impedance had decreased to 595 Ω (IQR 575-645), and median pacing threshold had increased to 3.3 V (IQR 1.8-4.5) at 0.24 ms. Explantation of one device revealed deep penetration of the Micra device into the myocardium.<br /><b>Conclusion</b><br />Short-term results after epicardial implantation of the Micra TPS at the left ventricular apex in lambs were satisfying. During mid-term follow-up, however, pacing thresholds increased, resulting in loss of capture in 2/10 animals. Penetration of one device into the myocardium was of concern. The concept of epicardial leadless pacing seems very attractive, and the current shape of the Micra TPS makes the device unsuitable for epicardial placement in growing organisms.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 05 Oct 2023; 25</small></div>

<div><h4>How to ablate the septo-pulmonary bundle: a case-based review of percutaneous ablation strategies to achieve roof line block.</h4><i>Tonko JB, Silberbauer J, Mann I</i><br /><AbstractText>Electrical conduction through cardiac muscle fibres separated from the main myocardial wall by layers of interposed adipose tissue are notoriously difficult to target by endocardial ablation alone. They are a recognised important cause for procedural failure due to the difficulties of delivering sufficient energy via the endocardial radiofrequency catheter to reach the outer epicardial layer without risking adverse events of the otherwise thin walled atria. Left atrial ablations for atrial fibrillation (AF) and tachycardia are commonly affected by the presence of several epicardial structures, with the septo-pulmonary bundle (SPB), Bachmann\'s bundle, and the ligament of Marshall all posing substantial challenges for endocardial procedures. Delivery of a transmural lesion set is essential for sustained pulmonary vein isolation and for conduction block across linear atrial lines which in turn has been described to translate into a reduced AF/atrial tachycardia recurrence rate. To overcome the limitations of endocardial-only approaches, surgical ablation techniques for epicardial or combined hybrid endo-epicardial ablations have been described to successfully target these connections. Yet, these techniques confer an increase in procedure complexity, duration, cost, and morbidity. Alternatively, coronary venous system ethanol ablation has been successfully employed by sub-selecting the vein of Marshall to facilitate mitral isthmus line block, although this approach is naturally limited to this area by the coronary venous anatomy. Increased awareness of the pathophysiological relevance of these epicardial structures and their intracardiac conduction patterns in the era of high-resolution 3D electro-anatomical mapping technology has allowed greater understanding of their contribution to the persistence of AF as well as failure to achieve transmural block by traditional ablation approaches. This might translate into novel catheter ablation strategies with procedural success rates comparable to surgical \'cut-and-sew\' techniques. This review aims to give an overview of percutaneous catheter ablation strategies to target the SPB, an important cause of failed block across the roof line and isolation of the left atrial posterior wall and/or the pulmonary veins. Existing and investigational technologies will be discussed and an outlook of future approaches provided.</AbstractText><br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 05 Oct 2023; 25</small></div>

<div><h4>Left bundle branch pacing with and without anodal capture: impact on ventricular activation pattern and acute haemodynamics.</h4><i>Ali N, Saqi K, Arnold AD, Miyazawa AA, ... Cole GD, Whinnett ZI</i><br /><b>Aims</b><br />Left bundle branch pacing (LBBP) can deliver physiological left ventricular activation, but typically at the cost of delayed right ventricular (RV) activation. Right ventricular activation can be advanced through anodal capture, but there is uncertainty regarding the mechanism by which this is achieved, and it is not known whether this produces haemodynamic benefit.<br /><b>Methods and results</b><br />We recruited patients with LBBP leads in whom anodal capture eliminated the terminal R-wave in lead V1. Ventricular activation pattern, timing, and high-precision acute haemodynamic response were studied during LBBP with and without anodal capture. We recruited 21 patients with a mean age of 67 years, of whom 14 were males. We measured electrocardiogram timings and haemodynamics in all patients, and in 16, we also performed non-invasive mapping. Ventricular epicardial propagation maps demonstrated that RV septal myocardial capture, rather than right bundle capture, was the mechanism for earlier RV activation. With anodal capture, QRS duration and total ventricular activation times were shorter (116 ± 12 vs. 129 ± 14 ms, P < 0.01 and 83 ± 18 vs. 90 ± 15 ms, P = 0.01). This required higher outputs (3.6 ± 1.9 vs. 0.6 ± 0.2 V, P < 0.01) but without additional haemodynamic benefit (mean difference -0.2 ± 3.8 mmHg compared with pacing without anodal capture, P = 0.2).<br /><b>Conclusion</b><br />Left bundle branch pacing with anodal capture advances RV activation by stimulating the RV septal myocardium. However, this requires higher outputs and does not improve acute haemodynamics. Aiming for anodal capture may therefore not be necessary.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 05 Oct 2023; 25</small></div>

<div><h4>Stellate ganglion ablation by conventional radiofrequency in patients with electrical storm.</h4><i>Rao BH, Lokre A, Patnala N, Padmanabhan TNC</i><br /><b>Aims</b><br />We report a series of patients with Electrical Storm (ES) who underwent bilateral stellate ganglion ablation by using conventional radio frequency (RFA).<br /><b>Methods and results</b><br />The procedure was done with fluoroscopic guidance using the COSMAN™ 1A RF Generator and a 22G RF needle (5 cm length and 5 mm active tip). Six patients, four male and two female (mean age 55 ± 7 years and mean LVEF-42 ± 21%) with ES underwent the procedure under fluoroscopic guidance. All patients experienced recurrent ICD shocks or required multiple external defibrillation shocks. There were no procedural complications. All patients survived free of ES at discharge. At a mean follow-up of 22 ± 8months, all were alive free of ES but two patients received appropriate shocks for VT and one patient had VT terminated by ATP.<br /><b>Conclusion</b><br />This small series of cases is a proof of concept that neuromodulation by conventional RFA targeting bilateral stellate ganglia appears safe, feasible, and effective in treating selected unstable patients with ES.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 05 Oct 2023; 25</small></div>

<div><h4>Length of Hospital Stay for Elective Electrophysiological Procedures: A Survey from the European Heart Rhythm Association.</h4><i>Boriani G, Imberti JF, Leyva F, Casado-Arroyo R, ... Pürerfellner H, Merino JL</i><br /><b>Background:</b><br/>and aims</b><br />Electrophysiological (EP) operations which have traditionally involved long hospital lengths of stay (LOS) are now being undertaken as day case procedures. The coronavirus disease (COVID)-19 pandemic served as an impetus for many centres to shorten LOS for EP procedures. This survey explores LOS for elective EP procedures in the modern era.<br /><b>Methods and results</b><br />An online survey consisting of 27 multiple choice questions was completed by 245 respondents from 35 countries. With respect to de novo cardiac implantable electronic device (CIED) implantations, day case procedures were reported for 79.5% of implantable loop recorders, 13.3% of PMs, 10.4% of implantable cardioverter defibrillators (ICDs) and 10.2% of CRT devices. With respect to CIED generator replacements, day case procedures were reported for 61.7% of PMs, 49.2% of ICDs and 48.2% of CRT devices. With regard to ablations, day case procedures were reported for 5.7% of atrial fibrillation (AF) ablations, 10.7% for left-sided ablations and 17.5% for right-sided ablations. A LOS ≥ 2 days for CIED implantation was reported for 47.7% of PM, 54.5% of ICDs and 56.9% of CRT devices; 54.5% of AF ablations, 42.2% of right-sided ablations and 46.1% of left sided ablations. Reimbursement (43-56%) and bed availability (20-47%) were reported to have no consistent impact on the organization of elective procedures.<br /><b>Conclusions</b><br />There is a wide variation in the LOS for elective EP procedures. The LOS for some procedures appears disproportionate to their complexity. Neither reimbursement or bed availability consistently influenced LOS.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 Oct 2023; epub ahead of print</small></div>

<div><h4>Dynamic changes of left atrial substrate over time following pulmonary vein isolation: The Progress-AF study.</h4><i>Marcon L, Bergonti M, Spera F, Saenen J, ... Heidbuchel H, Sarkozy A</i><br /><b>Background</b><br />Little is known about dynamic changes of the left atrial (LA) substrate over time in patients with atrial fibrillation (AF).<br /><b>Aim</b><br />To evaluate substrate changes following pulmonary vein isolation (PVI).<br /><b>Methods</b><br />In our prospective observational study, consecutive patients undergoing first PVI-only and redo ablation were included. High-density maps of the two procedures were compared. Progression or Regression was diagnosed if significant concordant decrease or increase in bipolar voltages in ≥2 segments was observed, respectively.<br /><b>Results</b><br />In 28 patients (61.2 ± 9.5 years, 39% female, 53.5% persistent AF), 111.013 voltage points from 56 high-density left atrial maps (1.982 points/patient) were analyzed. Comparing the high-density maps of the first and second procedure, in the Progression group (17 patients, 61%) there was a decrease in global (-35%, p<0.001) and all regional voltages. In the Regression group (11 patients, 39%) there was an increase in global (+43%, p<0.001) and regional voltages. Comparing the Progression to the Regression group, the area of Low Voltage Zone (LVZ) increased (+3.5 vs. -4.5cm2, p<0.001) and LA activation time prolonged (+8.0 vs -9.1ms, p=0.005). Baseline clinical parameters did not predict progression or regression. In patients with substrate progression, PVs were more frequently isolated (p=0.02) and the AF pattern at recurrence was more frequently persistent (p=0.005).<br /><b>Conclusions</b><br />Our study describes bidirectional dynamic properties of the LA substrate with concordant either progressive or regressive changes. Regression occurs with reduced AF burden after the first procedure while progression is associated with persistent AF recurrence despite durable PV isolation. The dynamic nature of LA substrate poses questions about LVZ based ablation strategies.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>CRT non-responder to responder conversion rate in the MORE-CRT MPP Trial.</h4><i>Leclercq C, Burri H, Paul Delnoy P, Rinaldi CA, ... Lee K, Thibault B</i><br /><b>Background:</b><br/>and aims</b><br />To assess the impact of MultiPoint™ Pacing (MPP) in cardiac resynchronization therapy (CRT) non-responders after six months of standard biventricular pacing (BiVP).<br /><b>Methods</b><br />The trial enrolled 5,850 patients who planned to receive a CRT device. The echocardiography core laboratory assessed CRT response before implant and after six months of BiVP; non-response to BiVP was defined as < 15% relative reduction in left ventricular end-systolic volume (LVESV). Echocardiographic non-responders were randomized in a 1:1 ratio to receive MPP (541 patients) or continued BiVP (570 patients) for an additional six months and evaluated the conversion rate to the echocardiographic response.<br /><b>Results</b><br />The characteristics of both groups at randomization were comparable. The percentage of non-responder patients who became responders to CRT therapy was 29.4% in the MPP arm and 30.4% in the BIVP arm (p=0.743). In patients with > 30 mm spacing between the two left ventricular pacing sites (MPP-AS), identified during the first phase as a potential beneficial subgroup, no significant difference in the conversion rate was observed.<br /><b>Conclusions</b><br />Our trial shows that approximately 30% of patients, who do not respond to CRT in the first six months, experience significant reverse remodeling in the following six months. This finding suggests that CRT benefit may be delayed or slowly incremental in a relevant proportion of patients and that the percentage of CRT responders may be higher than what has been described in short/middle-term studies. MPP does not improve CRT response in non-responders to BiVP, even with MPP-AS.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 30 Sep 2023; epub ahead of print</small></div>

<div><h4>Lead Management in Patients Undergoing Percutaneous Tricuspid Valve Replacement or Repair: A \"Heart Team\" Approach.</h4><i>Gabriels JK, Schaller RD, Koss E, Rutkin BJ, Carillo RG, Epstein LM</i><br /><AbstractText>Clinically significant tricuspid regurgitation (TR) has historically been managed with either medical therapy or surgical interventions. More recently, percutaneous transcatheter tricuspid valve (TV) replacement and tricuspid transcatheter edge-to-edge repair have emerged as alternative treatment modalities. Patients with cardiac implantable electronic devices (CIEDs) have an increased incidence of TR. Severe TR in this population can occur for multiple reasons, but most often results from the interactions between the CIED lead and the TV apparatus. Management decisions in patients with CIED leads and clinically significant TR, who are undergoing evaluation for a percutaneous TV intervention, need careful consideration as a transvenous lead extraction (TLE) may both worsen and improve TR severity. Furthermore, given the potential risks of \"jailing\" a CIED lead at the time of a percutaneous TV intervention (lead fracture, risk of subsequent infections), consideration should be given to performing a TLE prior to a percutaneous TV intervention. The purpose of this \"state-of-the-art\" review is to provide an overview of the causes of TR in patients with CIEDs, discuss the available therapeutic options for patients with TR and CIED leads and to advocate for including a lead management specialist as a member of the \"Heart Team\" when making treatment decisions in patients TR and CIED leads.</AbstractText><br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 29 Sep 2023; epub ahead of print</small></div>

<div><h4>Time-trend treatment effect of Cardiac Resynchronization Therapy with or without Defibrillator on Mortality -A Systematic Review And Meta-Analysis.</h4><i>Veres B, Fehérvari P, Engh MA, Hegyi P, ... Merkely B, Kosztin A</i><br /><b>Background</b><br />and aim: This study aimed to investigate the treatment effect of Cardiac Resynchronization Therapy with Defibrillator (CRT-D) on mortality compared to CRT-Pacemaker (CRT-P) and identify subgroups. Moreover, to assess the time-trend on treatment effect and the characteristics of patients while the indications have changed in the last decades.<br /><b>Methods</b><br />PubMed, CENTRAL and Embase up to October 2021 were screened for studies comparing CRT-P and CRT-D, focusing on mortality. Altogether 26 observational studies were selected comprising 128,030 CRT patients, including 55,469 with CRT-P, and 72,561 with CRT-D device.<br /><b>Results</b><br />CRT-D was able to reduce all-cause mortality by almost 20% over CRT-P (aHR:0.85; 95%CI:0.76-0.94; p<0.01) even in propensity-matched studies (HR:0.83; 95%CI:0.80-0.87; p<0.001), but not in those with non-ischemic etiology (HR 0.95, 95%CI:0.79-1.15; p=0.19) or over 75 years (HR 1.08, 95%CI 0.96-1.21; p=0.17). When treatment effect on mortality was investigated by the median year of inclusion, there was a difference between studies released before 2015 and those thereafter. Time-trend effects could be also observed in patients\' characteristics: CRT-P candidates were getting older and the prevalence of ischemic etiology were increasing over time.Conclusion: The results of this systematic review of observational studies, mostly retrospective with meta-analysis, suggest that patients with CRT-D had a lower risk of mortality compared to CRT-P. However, subgroups could be identified, where CRT-D was not superior such as non-ischemic and older patients. An improved treatment effect of CRT-D on mortality could be observed between the early and late studies partly related to the changed characteristics of CRT candidates.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 28 Sep 2023; epub ahead of print</small></div>

<div><h4>Procedural outcome and follow-up of stylet-driven leads compared to lumenless leads for left bundle branch area pacing.</h4><i>Sritharan A, Kozhuharov N, Masson N, Bakelants E, Valiton V, Burri H</i><br /><b>Aims</b><br />Left bundle branch area pacing (LBBAP) is most often delivered using lumenless leads (LLL), but may also be performed using stylet-driven leads (SDL). There are limited reports on comparison of these tools, mainly limited to reports describing initial operator experience or without detailed procedural data. Our aim was to perform an in-depth comparison of SDLs and LLLs for LBBAP at implantation and follow-up in a larger cohort of patients with experience that extends beyond that of the initial learning curve.<br /><b>Methods and results</b><br />A total of 306 consecutive patients (age 77±11 years, 183 males) undergoing LBBAP implantation at a single centre were prospectively included. The population was split into two groups of 153 patients, based upon initial use of a SDL (from four manufacturers) or a LLL. After having discounted the initial learning curve of 50 patients, there was no difference in success rate between initial use of lead type (96.0% with SDL versus 94.3% with LLL, p = 0.56). There were no significant differences in success between lead models. ECG and electrical parameters were comparable between the groups. Post-operative macro-dislodgement occurred in 4.3% of patients (essentially within the first day following implantation) and presumed micro-dislodgement with loss of conduction system capture or rise in threshold (occurring mostly during the first month) was observed in 4.7% of patients, without differences between groups.<br /><b>Conclusions</b><br />LBBAP may be safely and effectively performed using either LLLs or SDLs, which provides implanters with alternatives for delivering this therapy.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 28 Sep 2023; epub ahead of print</small></div>

<div><h4>Safety and success of transvenous lead extraction using excimer laser sheaths: a meta-analysis of over 1700 patients.</h4><i>Rinaldi CA, Diemberger I, Biffi M, Gao YR, ... Epstein LM, Defaye P</i><br /><b>Background:</b><br/>and aims</b><br />While numerous studies have demonstrated favorable safety and efficacy of the excimer laser sheath for transvenous lead extraction (TLE) in smaller cohorts, comprehensive large-scale investigations with contemporary data remain scarce. This study aims to evaluate the safety and performance of laser assisted TLE through a meta-analysis of contemporary data.<br /><b>Methods</b><br />A systematic literature search was conducted to identify articles which assessed the safety and performance of the SLS II and GlideLight Excimer laser sheaths in TLE procedures between April 1, 2016 and March 31, 2021. Safety outcomes included procedure-related death and major/minor complications. Performance outcomes included procedural and clinical success rates. A random-effects, inverse-variance-weighting meta-analysis was performed to obtain the weighted average of the evaluated outcomes.<br /><b>Results</b><br />In total, 17 articles were identified and evaluated, including 1,729 patients with 2,887 leads. Each patient, on average, had 2.3 ± 0.3 leads with a dwell time of 7.9 ± 3.0 years. The TLE procedural successes rate was 96.8% (1,440/1,505; 95% CI: [94.9%-98.2%]) per patient and 96.3% (1,447/1,501; 95% CI: [94.8%-97.4%]) per lead, and the clinical success rate per patient was 98.3% (989/1,010, 95% CI: [97.4%-99.0%]). The procedure-related death rate was 0.08% (7/1,729, 95% CI: [0.00%, 0.34%]), with major and minor complication rates of 1.9% (41/1,729; 95% CI: [1.2%-2.8%]) and 1.9% (58/1,729; 95% CI: [0.8%-3.6%]), respectively.<br /><b>Conclusion</b><br />This meta-analysis demonstrated that excimer laser sheath assisted TLE has high success and low procedural mortality rates. It provides clinicians a reliable and valuable resource for extracting indwelling cardiac leads which require advanced extraction techniques.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 27 Sep 2023; epub ahead of print</small></div>

<div><h4>Insight into the relationship between resting heart rate and atrial fibrillation: A Mendelian Randomization study.</h4><i>Klevjer M, Rasheed H, Romundstad PR, Madssen E, Brumpton BM, Bye A</i><br /><b>Background:</b><br/>and aims</b><br />A low resting heart rate (RHR) implies a more efficient heart function and a lower risk of cardiovascular disease. However, observational studies have reported a U-shaped association between RHR and atrial fibrillation (AF). In contrast, Mendelian randomization (MR) studies have found an inverse causal association between RHR and AF. Hence, the causal nature of the relationship is not clear. The aim is to investigate the causal association and its shape between RHR on AF using linear and non-linear MR (NLMR).<br /><b>Methods</b><br />Linear and non-linear MR were performed on individual-level data in the Trøndelag Health Study (HUNT) and UK Biobank (UKB). HUNT consists of 69,155 individuals with 7,062 AF cases, while UKB provides data on 431,852 individuals with 20,452 AF cases.<br /><b>Results</b><br />The linear MR found an inverse relationship between RHR and AF with an OR = 0.95 (95% confidence interval (CI): 0.93-0.98) and OR = 0.96 (95% CI: 0.95-0.97) per unit decrease in RHR in HUNT and UKB, respectively. The NLMR was supportive of an inverse linear relationship in both HUNT and UKB for RHR values <90 beats per minute (bpm). Several sensitivity analyses were also consistent.<br /><b>Conclusion</b><br />In contrast with the current observational knowledge of RHR and AF, an inverse causal association between RHR and AF was demonstrated in both linear and non-linear MR for RHR values up to 90 bpm. Further exploring the underlying mechanisms of the genetic instrument for RHR may shed light on whether pleiotropy is biasing this association.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 21 Sep 2023; epub ahead of print</small></div>

<div><h4>AF Cryoablation is an effective day case treatment: The United Kingdom PolarX versus AFA experience.</h4><i>Honarbakhsh S, Martin CA, Mesquita J, Herlekar R, ... Schilling RJ, Hunter RJ</i><br /><b>Background</b><br />Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation (AF). There are limited data on the PolarX Cryoballoon.<br /><b>Aims</b><br />The study aimed to establish the safety, efficacy, and feasibility of same day discharge for Cryoballoon PVI.<br /><b>Methods</b><br />Multi-centre study across 12 centres. Procedural metrics, safety profile and procedural efficacy of the PolarX Cryoballoon with the Artic Front Advance (AFA) Cryoballoon was compared in a cohort large enough to provide definitive comparative data.<br /><b>Results</b><br />1688 patients underwent PVI with cryoablation (50% PolarX and 50% AFA). Successful PVI was achieved with 1677 (99.3%) patients with 97.2% (n = 1641) performed as day case procedures with a complication rate of <1%. Safety, procedural metrics, and efficacy of the PolarX Cryoballoon was comparable to the AFA cohort. The PolarX Cryoballoon demonstrated a nadir temperature of 54.6 ± 7.6℃, temperature at 30-seconds of 38.6 ± 7.2℃, time to -40℃ of 34.1 ± 13.7 s and time to isolation (TTI) of 49.8 ± 33.2 s. Independent predictors for achieving PVI included time to reach -40 ℃ (OR 1.34; p < 0.001) and nadir temperature (OR 1.24; p < 0.001) with an optimal cut-off of ≤34 seconds (AUC 0.73; p < 0.001) and nadir temperature of ≤ -54.0℃ (AUC 0.71; p < 0.001) respectively.<br /><b>Conclusions</b><br />This large-scale UK multicentre study has shown that Cryoballoon PVI is a safe effective day case procedure. PVI using the PolarX Cryoballoon was similarly safe, and effective as the AFA Cryoballoon. The cryoablation metrics achieved with the PolarX Cryoballoon were different to that reported with the AFA Cryoballoon. Modified cryoablation targets are required when utilizing the PolarX Cryoballoon.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 21 Sep 2023; epub ahead of print</small></div>

<div><h4>Comparisons of Effectiveness and Safety between On-label Dosing, Off-label Underdosing and Off-label Overdosing in Asian and Non-Asian Atrial Fibrillation Patients Treated with Rivaroxaban: A Systematic Review and Meta-analysis of Observational Studies.</h4><i>Chan YH, Chan CY, Chen SW, Chao TF, Lip GYH</i><br /><b>Background:</b><br/>and aims</b><br />Limited real-world data show that rivaroxaban following dosage criteria from either ROCKET AF (20mg/day or 15mg/day if creatinine clearance [CrCl]<50ml/min) or J-ROCKET AF (15mg/day or 10mg/day if CrCl<50ml/min) are associated with comparable risks of thromboembolism and bleeding with each other in patients with non-valvular atrial fibrillation (NVAF). We are aimed to study whether these observations differ between Asian and non-Asian subjects.<br /><b>Methods</b><br />A systematic review and meta-analysis with random effects was conducted to estimate the aggregate hazard ratio (HR) and 95% confidence interval (CI) using PubMed and MEDLINE databases from September 8, 2011 to December 31, 2022 searched for adjusted observational studies that reported relevant clinical outcomes of NVAF patients receiving rivaroxaban 10mg/day if CrCl>50ml/min, on-label dose rivaroxaban eligible for ROCKET AF or J-ROCKET AF, and rivaroxaban 20mg/day if CrCl<50ml/min. Effectiveness and safety endpoints were compared between ROCKET AF and J-ROCKET AF dosing regimen in Asian and non-Asian subjects, separately. Also, risks of events of rivaroxaban 10mg/day despite of CrCl>50ml/min and rivaroxaban 20mg/day despite of CrCl<50ml/min were compared to that of \"ROCKET AF/J-ROCKET AF dosing\". Sensitivity analyses were performed by sequential elimination of each study from the pool. The meta-regression analysis was performed to explore the influence of potential factors on the effectiveness and safety outcomes.<br /><b>Results</b><br />Eighteen studies involving 67,571 Asian and 54,882 non-Asian patients were included. Rivaroxaban following J-ROCKET AF criteria was associated with comparable risks of thromboembolism in the Asian subgroup, whereas rivaroxaban following J-ROCKET AF criteria was associated with higher risks of all-cause mortality (HR:1.30; 95%CI:1.05-1.60) compared with that of ROCKET AF criteria in the non-Asian population. There were no differences in risks of major bleeding between rivaroxaban following J-ROCKET AF versus ROCKET AF criteria either in the Asian or non-Asian population. Use of rivaroxaban 10mg despite of CrCl>50ml/min was associated with a higher risk of thromboembolism (HR:1.64; 95%CI:1.28-2.11) but lower risk of major bleeding (HR:0.72; 95%CI:0.57-0.90) compared with eligible dosage criteria. Use of rivaroxaban 20mg despite of CrCl<50ml/min was associated with worse clinical outcomes in the risks of thromboembolism (HR:1.32; 95%CI:1.09-1.59), mortality (HR:1.33; 95%CI:1.10-1.59) and major bleeding (HR:1.26; 95%CI:1.03-1.53) compared with eligible dosage criteria. The pooled results were generally in line with the primary effectiveness and safety outcomes by removing a single study at one time. Meta-regression analyses failed to detect the bias in most potential patient characteristics associated with the clinical outcomes.<br /><b>Conclusions</b><br />Rivaroxaban dosing regimen following J-ROCKET criteria may serve as an alternative to ROCKET-AF criteria for the Asian population with NVAF, whereas the dosing regimen following ROCKET AF criteria was more favorable for the non-Asian population. Use of rivaroxaban 10mg despite of CrCl>50ml/min was associated with a higher risk of thromboembolism but a lower risk of major bleeding, while use of rivaroxaban 20mg despite of CrCl<50ml/min was associated with worse outcome in most clinical events.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 20 Sep 2023; epub ahead of print</small></div>

<div><h4>Optimal Left Ventricular Ejection Fraction in Risk Stratification of Patients with Cardiac Sarcoidosis.</h4><i>Hutt E, Vega Brizneda M, Goldar G, Aguilera J, ... Ribeiro Neto ML, Jellis CL</i><br /><b>Background</b><br />Identifying patients with cardiac sarcoidosis (CS) who are at increased risk of sudden cardiac death (SCD) poses a clinical challenge.<br /><b>Aims</b><br />We sought to identify the optimal cutoff for LVEF in predicting ventricular arrhythmia (VA) and all-cause mortality and to identify clinical and imaging risk factors in patients with known CS.<br /><b>Methods</b><br />This retrospective cohort included 273 patients with well-established CS. The primary endpoint was a composite of VA and all-cause mortality. A modified receiver operating curve analysis was utilized to identify the optimal cutoff for LVEF in predicting the primary composite endpoint. Cox proportional hazard regression analysis was used to identify independent risk factors of the outcomes.<br /><b>Results</b><br />At median follow-up of 7.9 years, the rate of the primary endpoint was 38% (83 VAs and 32 all-cause deaths). The 5-year overall survival rate was 97%. The optimal cutoff LVEF for the primary composite endpoint was 42% in the entire cohort and in subjects without a history of VA. Younger age, history of VA, lower LVEF and any presence of scar by CMR and/or PET were found to be independent risk factors for the primary endpoint and for VA, whereas lower LVEF, baseline NT-proBNP and any presence of scar were independent risk factor of all-cause mortality.<br /><b>Conclusion</b><br />Among patients with CS, a mild reduction in LVEF of 42% was identified as the optimal cutoff for predicting VA and all-cause mortality. Prior VA and scar by CMR or PET are strong risk factors for future VA and all-cause mortality.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 18 Sep 2023; epub ahead of print</small></div>

<div><h4>Comparison of in-hospital outcomes and complications of Leadless Pacemaker and Traditional Transvenous Pacemaker Implantation.</h4><i>Alhuarrat MAD, Khawrawala A, Renjithlal S, Magdi Eid M, ... Grushko M, Di Biase L</i><br /><b>Introduction</b><br />Since their introduction in 1958, traditional cardiac pacemakers have undergone considerable upgrades over the years, but they continue to have a complication rate of around 3.8% to 12.4%. There are no randomized controlled trials comparing outcomes of leadless pacemakers (LPM) with single chamber transvenous pacemakers (TV-VVI).<br /><b>Objective</b><br />Assess the differences in the procedural complications and in-hospital outcomes between LPM and TV-VVI implants.<br /><b>Methods</b><br />We queried the national inpatient database from 2016-2019 to include adult patients undergoing LPM and TV-VVI. Admissions for leadless and single lead transvenous pacemakers were identified by their appropriate ICD-10 codes. Complications were identified using ICD-10 codes that mostly represent initial encounter. The difference in outcomes was assessed using Multivariable logistic regression and 1:1 propensity score matching between the two cohorts.<br /><b>Results</b><br />35,430 expanded sample of admissions was retrieved of which 27,650(78%) underwent TV-VVI with a mean age 81.3±9.4 years and 7,780(22%) underwent LPM with a mean age of 77.1±12.1 years. LPM group had a higher likelihood of in-hospital mortality (aOR:1.63, 95%CI[1.29-2.05], p <0.001), vascular complications (aOR:7.54, 95%CI[3.21-17.68], p<0.001), venous thromboembolism (aOR:3.67, 95%CI [2.68-5.02], p<0.001), cardiac complications (aOR:1.79, 95%CI[1.59-2.03], p<0.001), device thrombus formation (aOR:5.03, 95% CI[2.55-9.92], p<0.001) and need for a blood transfusion (aOR:1.54, 95%CI[1.14-2.07], p<0.005, respectively). TV-VVI group had higher likelihood of in-hospital pulmonary complications (aOR:0.68, 95%CI[0.54-0.87], p<0.002) and need for device revisions (aOR:0.42, 95%CI[0.23-0.76], p<0.004).<br /><b>Conclusion</b><br />There is a higher likelihood of all-cause in-hospital mortality and complications following LPM implantation in comparison to TV-VVI. This could be related to higher co-morbidities in the LPM group. Clinical trials aimed to accurately compare between these two groups should be undertaken.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 15 Sep 2023; epub ahead of print</small></div>

<div><h4>Outcomes of patients with atrial fibrillation on oral anticoagulation with and without heart failure: the ETNA-AF-Europe registry.</h4><i>Schnabel RB, Ameri P, Siller-Matula JM, Diemberger I, ... De Caterina R, Kirchhof P</i><br /><b>Background:</b><br/>and aims</b><br />Heart failure (HF) is a risk factor for major adverse events in atrial fibrillation (AF). Whether this risk persists on non-vitamin K oral anticoagulants (NOACs) and varies according to left ventricular ejection fraction (LVEF) is debated.<br /><b>Methods</b><br />We investigated the relation of HF in the ETNA-AF-Europe registry, a prospective, multi-centre, observational study with an overall 4-year follow-up of edoxaban-treated AF patients. We report 2-year follow-up for ischaemic stroke/transient ischaemic attack (TIA)/systemic embolic events (SEE), major bleeding, and mortality.<br /><b>Results</b><br />Of the 13,133 patients, 1,854 (14.1%) had HF. LVEF was available for 82.4% of HF patients and was <40% in 671 (43.9%) and ≥40% in 857 (56.1%). Patients with HF were older, more often men and had more comorbidities. Annualised event rates (AnERs) of any stroke/SEE were 0.86%/year and 0.67%/year in patients with and without HF. Compared with patients without HF, those with HF also had higher AnERs for major bleeding (1.73%/year versus 0.86%/year) and all-cause death (8.30%/year versus 3.17%/year). Multivariate Cox proportional models confirmed HF as a significant predictor of major bleeding (hazard ratio [HR] 1.65, 95% confidence interval [CI]:1.20-2.26) and all-cause death (HF with LVEF <40% [HR 2.42, 95%CI:1.95-3.00] and HF with LVEF ≥40% [HR 1.80, 95%CI:1.45-2.23]), but not of ischaemic stroke/TIA/SEE.<br /><b>Conclusions</b><br />Anticoagulated patients with HF at baseline featured higher rates of major bleeding and all-cause death, requiring optimised management and novel preventive strategies. NOAC treatment was similarly effective in reducing risk of ischaemic events in patients with or without concomitant HF.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 15 Sep 2023; epub ahead of print</small></div>

<div><h4>Optimising Patient Selection for Primary Prevention ICD Implantation: Utilising Multimodal Machine Learning to Assess Risk of ICD Non-Benefit.</h4><i>Kolk MZH, Ruipérez-Campillo S, Deb B, Bekkers E, ... Narayan SM, Tjong FVY</i><br /><b>Background</b><br />Left ventricular ejection fraction (LVEF) is suboptimal as a sole marker for predicting sudden cardiac death (SCD). Machine learning (ML) provides new opportunities for personalised predictions using complex, multimodal data. This study aimed to determine if risk stratification for implantable cardioverter defibrillator (ICD) implantation can be improved by ML models that combine clinical variables with 12-lead electrocardiograms (ECG) time-series features.<br /><b>Methods</b><br />A multicentre study of 1010 patients (64.9 ±10.8 years, 26.8% female) with ischaemic, dilated, or non-ischaemic cardiomyopathy, and LVEF≤35% implanted with an ICD between 2007 and 2021 for primary prevention of SCD in two academic hospitals was performed. For each patient, a raw 12-lead, 10-second ECG obtained within 90 days before ICD implantation and clinical details were collected. Supervised ML models were trained and validated on a development cohort (n=550) from Hospital A to predict ICD non-arrhythmic mortality at 3-year follow-up (i.e. mortality without prior appropriate ICD-therapy). Model performance was evaluated on an external patient cohort from Hospital B (n=460).<br /><b>Results</b><br />At 3-year follow-up, 16.0% of patients had died, with 72.8% meeting criteria for non-arrhythmic mortality. Extreme gradient boosting models identified patients with non-arrhythmic mortality with an area under the receiver operating characteristic curve (AUROC) of 0.90 (95% CI 0.80-1.00) during internal validation. In the external cohort, the AUROC was 0.79 (95% CI 0.75-0.84).<br /><b>Conclusions</b><br />ML models combining ECG time-series features and clinical variables were able to predict non-arrhythmic mortality within 3 years after device implantation in a primary prevention population, with robust performance in an independent cohort.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 15 Sep 2023; epub ahead of print</small></div>

<div><h4>Asymptomatic Atrial Fibrillation among Hospitalized Patients: Clinical Correlates and In-Hospital Outcomes in the Improving Care for Cardiovascular Disease in China-Atrial Fibrillation (CCC-AF).</h4><i>Lin J, Wu XY, Long DY, Jiang CX, ... Dong JZ, Ma CS</i><br /><b>Aims</b><br />The clinical correlates and outcomes of asymptomatic atrial fibrillation (AF) in hospitalized patients are largely unknown. We aimed to investigate the clinical correlates and in-hospital outcomes of asymptomatic AF in hospitalized Chinese patients.<br /><b>Methods and results</b><br />We conducted a cross-sectional registry study of inpatients with AF enrolled in the Improving Care for Cardiovascular Disease in China-Atrial Fibrillation Project between February 2015 and December 2019. We investigated the clinical characteristics of asymptomatic AF and the association between the clinical correlates and in-hospital outcomes of asymptomatic AF. Asymptomatic and symptomatic AF were defined according to the European Heart Rhythm Association score.Asymptomatic patients were more commonly male (56.3%) and had more comorbidities such as hypertension (57.4%), diabetes mellitus (18.6%), peripheral artery disease (PAD) (2.3%), coronary artery disease (CAD) (55.5%), previous history of stroke/transient ischemic attack (TIA) (17.9%), and myocardial infarction (MI) (5.4%); however, they had less prevalent heart failure (9.6%) or left ventricular ejection fractions ≤40% (7.3%). Asymptomatic patients were more often hospitalized with a non-AF diagnosis as the main diagnosis and were more commonly first diagnosed with AF (23.9%) and long-standing persistent/permanent AF (17.0%). The independent determinants of asymptomatic presentation were male sex, long-standing persistent AF/permanent AF, previous history of stroke/TIA, MI, PAD, and previous treatment with antiplatelet drugs. The incidence of in-hospital clinical events, including all-cause death, ischemic stroke/TIA, and acute coronary syndrome (ACS), was higher in asymptomatic patients than in symptomatic patients, and asymptomatic clinical status was an independent risk factor for in-hospital all-cause death, ischemic stroke/TIA, and ACS.<br /><b>Conclusions</b><br />Asymptomatic atrial fibrillation is common among hospitalized patients with AF. Asymptomatic clinical status is associated with male sex, comorbidities, and a higher risk of in-hospital outcomes. The adoption of effective management strategies for patients with AF should not be solely based on clinical symptoms.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 15 Sep 2023; epub ahead of print</small></div>

<div><h4>Implementation and first outcomes of a novel standard operating procedure for preprocedural transoesophageal echocardiography screening in course of atrial arrhythmia ablation.</h4><i>Dittrich S, Kece F, Scheurlen C, van den Bruck JH, ... Lüker J, Steven D</i><br /><b>Background:</b><br/>and aims</b><br />Preprocedural TEE screening for LA thrombi is standard of care in many centers performing AF ablation. However, TEE imposes procedural risks for patients and is often challenging to implement in daily practice, besides causing patient discomfort. At our center, a novel standard operating procedure (SOP) was implemented, aiming to identify patients that can be exempt from TEE screening. We aimed to assess, whether this screening approach may reduce preprocedural TEEs without imposing patients of higher risks for cerebrovascular events (CVE).<br /><b>Methods</b><br />Data of 1874 consecutive patients treated by catheter ablation of left atrial arrhythmias between 2018 and 2022 was retrospectively analyzed. A cohort of 937 patients, where decision to perform TEE screening was based on a new SOP (considering rhythm at admission, CHA2DS2-VASc-Score, sufficient anticoagulation), was compared to a matched cohort receiving TEE before every procedure. Number of performed TEEs and incidences of CVEs were compared.<br /><b>Results</b><br />Implementation of the new SOP led to a 67% reduction in TEEs performed (old SOP: 933 vs. new SOP: 305). No significant differences between the groups were detected regarding TIA (old SOP: 5 vs. new SOP: 3; p = 0.48) and stroke (no events). No solid thrombi were detected during TEE screening.<br /><b>Conclusion</b><br />The number of preprocedural screening TEEs before AF ablation procedures can be safely reduced by applying risk stratification based on rhythm at admission and CHA2DS2-VASc-Score, if anticoagulation was performed properly.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 15 Sep 2023; epub ahead of print</small></div>

<div><h4>Differences in Atrial Substrate Localization using LGE-MRI, Electrogram Voltage and Conduction Velocity - A Cohort Study Using a Consistent Anatomical Reference Frame in Patients with Persistent Atrial Fibrillation.</h4><i>Nairn D, Eichenlaub M, Müller-Edenborn B, Huang T, ... Loewe A, Jadidi A</i><br /><b>Background:</b><br/>and aims</b><br />Electro-anatomical voltage, conduction velocity (CV) mapping and late gadolinium enhancement magnetic resonance imaging (LGEMRI) have been correlated with atrial cardiomyopathy (ACM). However, the comparability between these modalities remains unclear. Aims: (1) Compare pathological substrate extent and location between current modalities. (2) Establish spatial histograms in a cohort. (3) Develop a new estimated optimised image intensity threshold (EOIIT) for LGE-MRI identifying patients with ACM. (4) Predict rhythm outcome after pulmonary vein isolation (PVI) for persistent atrial fibrillation.<br /><b>Methods</b><br />36 ablation-naive persistent AF patients underwent LGE-MRI and high-definition electro-anatomical mapping in SR. LGE areas were classified using the UTAH, image intensity ratio (IIR > 1.20) and new EOIIT method for comparison to LVS and slow conduction areas <0.2 m/s. ROC analysis was used to determine LGE thresholds optimally matching LVS. ACM was defined as low voltage substrate (LVS) extent ≥ 5% of the left atrium (LA) surface at <0.5 mV.<br /><b>Results</b><br />The degree and distribution of detected pathological substrate varied significantly (p < 0.001) across the mapping modalities: 3% (IQR 0-12%) of the LA displayed LVS < 0.5 mV vs. 14% (3-25%) slow conduction areas < 0.2 m/s vs. 16% (6-32%) LGE with the UTAH method vs. 17% (11-24%) using IIR > 1.20, with most discrepancies on the posterior LA. Optimised image intensity thresholds and each patient\'s mean blood pool intensity correlated linearly (R2 = 0.89, p < 0.001). Concordance between LGE-MRI-based and LVS-based ACM diagnosis improved with the novel EOIIT applied at the anterior LA (83% sensitivity, 79% specificity, AUC: 0.89) in comparison to the UTAH method (67% sensitivity, 75% specificity, AUC: 0.81) and IIR > 1.20 (75% sensitivity, 62% specificity, AUC: 0.67).<br /><b>Conclusion</b><br />Discordances in detected pathological substrate exist between LVS, CV and LGE-MRI in the LA, irrespective of the LGE detection method. The new EOIIT method improves concordance of LGE-MRI-based ACM diagnosis with LVS in ablation-naive AF patients but discrepancy remains particularly on the posterior wall. All methods may enable prediction of rhythm outcome after PVI in patients with persistent AF.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 15 Sep 2023; epub ahead of print</small></div>

<div><h4>Catheter ablation of atrial tachyarrhythmias in patients with atrioventricular septal defect.</h4><i>Waldmann V, Bessière F, Gardey K, Hascoët S, ... Combes N, de Groot N</i><br /><b>Background:</b><br/>and aims</b><br />The incidence of atrial tachyarrhythmias is high in patients with atrioventricular septal defect (AVSD). No specific data on catheter ablation have been reported so far in this population. We aimed to describe the main mechanisms of atrial tachyarrhythmias in patients AVSD and to analyze outcomes after catheter ablation.<br /><b>Methods</b><br />This observational multicentric cohort study enrolled all patients with AVSD referred for catheter ablation of an atrial tachyarrhythmia at 6 tertiary centers from 2004 to 2022. The mechanisms of the different tachyarrhythmias targeted were described and outcomes were analyzed.<br /><b>Results</b><br />Overall, 56 patients (38.1±17.4 years, 55.4% females) were included. A total of 87 atrial tachyarrhythmias were targeted (mean number of 1.6 per patient). Regarding main circuits involved, a cavo-annular isthmus-dependent IART was observed in 41 (73.2%) patients and an IART involving the right lateral atriotomy in 10 (17.9%) patients. Other tachyarrhythmias with heterogeneous circuits were observed in 13 (23.2%) patients including 11 left-sided and 4 right-sided tachyarrhythmias. Overall, an acute success was achieved in 54 (96.4%) patients and no complication was reported. During a mean follow-up of 2.8±3.8 years, 22 (39.3%) patients had at least one recurrence. Freedom from atrial tachyarrhythmia recurrences was 77.5% at one year. Among 15 (26.8%) patients who underwent repeated ablation procedures, heterogeneous circuits including biatrial and left-sided tachyarrhythmias were more frequent.<br /><b>Conclusion</b><br />In patients with AVSD, most circuits involve the cavo-annular isthmus, but complex mechanisms are frequently encountered in patients with repeated procedures. The acute success rate is excellent, although recurrences remain common during follow-up.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 11 Sep 2023; epub ahead of print</small></div>

<div><h4>Recurrences of ventricular tachycardia after stereotactic arrhythmia radioablation arise outside the treated volume: analysis of the swiss cohort.</h4><i>Siklody CH, Schiappacasse L, Jumeau R, Reichlin T, ... Ozsahin EM, Pruvot E</i><br /><b>Background:</b><br/>and aims</b><br />Stereotactic arrhythmia radioablation (STAR) has been recently introduced for the management of therapy-refractory ventricular tachycardia (VT). VT recurrences have been reported after STAR but the mechanisms remain largely unknown. We analyzed recurrences in our patients after STAR.<br /><b>Methods</b><br />From 09.2017 to 01.2020, 20 patients (68±8y, LVEF 37±15%) suffering from refractory VT were enrolled, 16/20 with a history of at least 1 electrical storm. Before STAR, an invasive electro-anatomical mapping (Carto3) of the VT substrate was performed. A mean dose of 23±2Gy was delivered to the planning target volume (PTV).<br /><b>Results</b><br />The median ablation volume was 26 ml (range 14-115) and involved the interventricular septum in 75% of patients. During the first 6 months after STAR, VT burden decreased by 92% (median value, from 108 to 10 VT/semester). After a median follow-up of 25 months, 12/20 (60%) developed a recurrence and underwent a redo ablation. VT recurrence was located in proximity of the treated substrate in 9 cases, remote from the PTV in 3 cases and involved a larger substrate over ≥3 LV segments in 2 cases. No recurrences occurred inside the PTV. Voltage measurements showed a significant decrease in both bipolar and unipolar signal amplitude after STAR.<br /><b>Conclusion</b><br />STAR is a new tool available for the treatment of VT, allowing for a significant reduction of VT burden. VT recurrences are common during follow-up, but no recurrences were observed inside the PTV. Local efficacy was supported by a significant decrease in both bipolar and unipolar signal amplitude.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 11 Sep 2023; epub ahead of print</small></div>

<div><h4>Clinical and Economic Outcomes of a Systematic Same-Day Discharge Program After Pulmonary Vein Isolation: Comparison between Cryoballoon versus Radiofrequency Ablation.</h4><i>Jimenez-Candil J, Hernandez J, Cruz Galban A, Blanco F, ... Oterino A, Sanchez PL</i><br /><b>Background:</b><br/>and aims</b><br />Same-day discharge (SDD) is feasible after pulmonary vein isolation (PVI). We aim to compare prospectively cryoballoon (CRYO) versus radiofrequency (RF) ablation in a systematic SDD program.<br /><b>Methods</b><br />We prospectively analyzed the 617 scheduled PVI performed consecutively at our institution (n = 377 CRYO, n = 240 RF) from April 1, 2019 to December 31, 2022 within a systematic program of SDD. The feasibility of SDD, the 10-day incidence of urgent/unplanned medical care after discharge (UUC-10), and the cost per procedure due to hospital resource use were studied. The 100 procedures performed during the previous year, in which patients were systematically hospitalized, were used as a control group.<br /><b>Results</b><br />SDD was achieved in 585/617 (95%) procedures, with a significant trend towards a higher monthly SDD rate from 2019 to 2022 (p = 0.03). The frequency of SDD was similar in CRYO (356/377; 94%) vs. RF (229/240; 95%). After SDD, the UUC-10 was 66/585 (11.3%), being similar for CRYO (41/356; 11.5%) and RF (25/229; 10.9%); p = 0.8 (log-rank test). Of these, 10 patients were re-hospitalized, with an identical rate in CRYO- (6/356; 1.7%) and RF-treated (4/229; 1.7%) patients and owing to similar causes (4 hematomas, 4 pericarditis, and 2 symptomatic sinus node dysfunction). SDD was associated with an average savings per procedure of 63% (p < 0.001), but no differences were found between the CRYO and RF (p = 0.8).<br /><b>Conclusions</b><br />In a systematic SDD program, feasibility (95%, increasing over time), safety (11% UUC-10, 1.7% re-hospitalizations), and savings (63% per procedure) were similar for CRYO and RF ablation.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>Patient perspectives on same-day discharge following catheter ablation for atrial fibrillation: Results from a patient survey as part of the monocentric FAST AFA trial.</h4><i>König S, Wohlrab L, Leiner J, Pellissier V, ... Hindricks G, Bollmann A</i><br /><b>Introduction</b><br />Same-day discharge (SDD) following catheter ablation (CA) of atrial fibrillation (AF) was already introduced in selected facilities in Europe but a widespread implementation has not yet succeeded. Data on patients\' perspectives is lacking. Therefore, we conducted a survey to address patients\' beliefs towards SDD and identify variables that are associated with their evaluation.<br /><b>Methods and results</b><br />As part of the prospective, monocentric FAST AFA trial, patients aged ≥20 years undergoing left atrial CA for AF were asked to participate in the survey consisting of a study-specific questionnaire, the AF knowledge scale and pre-defined PROMs. The study cohort was stratified based on SDD willingness and a logistic regression analysis was used to identify predictors for patients\' valuation. Between 07/26/2021-07/01/2022, 256 of 376 screened patients consented to study participation of whom 248 (mean age 61.8 years, 33.9% female) completed the SDD survey. Of them, 50.0% were willing to have SDD concepts integrated into their clinical course with increased patient comfort (27.5%), shorter waiting times (14.6%) and a cost-efficient treatment (14.0%) being imaginable benefits. In contrast, expressed concerns included uncertainties with occurring complaints (50.6%), and the insufficient recognition (47.8%) and treatment (48.9%) of complications. EHRA class at baseline and inpatient treatments within the preceding year were predictors for SDD willingness whereas comorbidity burden or AF knowledge were not.<br /><b>Conclusion</b><br />We provide a detailed survey expressing patients\' beliefs towards SDD following left atrial CA. Our findings may facilitate adequate patient selection to improve the future implementation of SDD programs in suitable cohorts.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 01 Sep 2023; epub ahead of print</small></div>

<div><h4>Performance of a multisensor implantable defibrillator algorithm for HF monitoring in the presence of atrial fibrillation.</h4><i>Boriani G, Bertini M, Manzo M, Calò L, ... Valsecchi S, D\'Onofrio A</i><br /><b>Aims</b><br />The HeartLogic Index combines data from multiple implantable cardioverter defibrillators (ICD) sensors and has been shown to accurately stratify patients at risk of heart failure (HF) events. We evaluated and compared the performance of this algorithm during sinus rhythm and during long-lasting atrial fibrillation (AF).<br /><b>Methods and results</b><br />HeartLogic was activated in 568 ICD patients from 26 centers. We found periods of ≥30 consecutive days with an atrial high-rate episode (AHRE)-burden <1 hour/day, and periods with an AHRE-burden ≥20 hours/day. We then identified patients who met both criteria during follow-up (AHRE group, N = 53), to allow pairwise comparison of periods. For control purposes, we identified patients with an AHRE-burden <1 h throughout their follow-up and implemented 2:1 propensity score matching versus the AHRE group (Matched non-AHRE group, N = 106). In the AHRE group, the rate of alerts was 1.2 (95%CI:1.0-1.5)/patient-year during periods with an AHRE-burden <1 hour/day and 2.0 (95%CI:1.5-2.6)/patient-year during periods with an AHRE-burden ≥20 hours/day (p = 0.004). The rate of HF hospitalizations was 0.34 (95%CI:0.15-0.69)/patient-year during IN-alert periods and 0.06 (95%CI:0.02-0.14)/patient-year during OUT-of-alert periods (p < 0.001). The IN/OUT-of-alert state incidence rate ratio of HF hospitalizations was 8.59 (95%CI:1.67-55.31) during periods with an AHRE-burden <1 hour/day and 2.70 (95%CI:1.01-28.33) during periods with an AHRE-burden ≥20 hours/day. In the Matched non-AHRE group, the rate of HF hospitalizations was 0.29 (95%CI:0.12-0.60)/patient-year during IN-alert periods, and 0.04 (95%CI:0.02-0.08)/patient-year during OUT-of-alert periods (p < 0.001). The incidence rate ratio was 7.11 (95%CI:2.19-22.44).<br /><b>Conclusions</b><br />Patients received more alerts during periods of AF. The ability of the algorithm to identify increased risk of HF events was confirmed during AF, despite a lower IN/OUT-of-alert incidence rate ratio in comparison with non-AF periods and non-AF patients.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 01 Sep 2023; epub ahead of print</small></div>

<div><h4>Determinants of acute irreversible electroporation lesion characteristics after pulsed field ablation: the role of voltage, contact, and adipose interference.</h4><i>Gasperetti A, Assis F, Tripathi H, Suzuki M, ... Karmarkar P, Tandri H</i><br /><b>Background</b><br />Pulsed field ablation (PFA) is a non-thermal ablative approach in which cardiomyocyte death is obtained through irreversible electroporation (IRE). Data correlating biophysical characteristics of IRE and lesion characteristics are limited.<br /><b>Objectives</b><br />To assess the effect of different procedural parameters (voltage, number of cycles (NoC), and contact) on lesion characteristics in a vegetal and animal model for IRE.<br /><b>Methods</b><br />Two hundred four Russet potatoes were used. PFA lesions were delivered on 3-cm cored potato specimens using a multi-electrode circular catheter with its dedicated IRE generator. Different voltage (from 300 to 1200 V) and NoC (from 1x to 5x) protocols were used. Impact of 0.5 mm and 1 mm catheter-to-specimen distance was tested. A swine animal model was then used to validate results observed in the vegetable model. Association between V, NoC, distance and lesion depth were assessed through linear regression.<br /><b>Results</b><br />An almost perfect linear association between lesion depth and voltage was observed (R2=0.95; p<0.001). A similarly linear relationship was observed between the NoC and lesion depth (R2=0.73; p<0.001). Compared with controls at full contact, a significant dampening on lesion depth was observed at 0.5 mm distance (1000V 2x: 2.11±0.12 vs 0.36±0.04, p<0.001; 2.63±0.10 vs 0.43±0.08, p<0.001). No lesions were observed at 1.0 mm distance.<br /><b>Conclusion</b><br />In a vegetal and animal model for IRE assessment, PFA lesion characteristics were found to be strongly dependent on voltage settings and NoC, with a quasi-linear relationship. Lack of catheter contact was associated with dampening in lesion depth.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 31 Aug 2023; epub ahead of print</small></div>