Journal: Europace

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Abstract

Electrocardiographic imaging for cardiac arrhythmias and resynchronization therapy.

Pereira H, Niederer S, Rinaldi CA

Use of the 12-lead electrocardiogram (ECG) is fundamental for the assessment of heart disease, including arrhythmias, but cannot always reveal the underlying mechanism or the location of the arrhythmia origin. Electrocardiographic imaging (ECGi) is a non-invasive multi-lead ECG-type imaging tool that enhances conventional 12-lead ECG. Although it is an established technology, its continuous development has been shown to assist in arrhythmic activation mapping and provide insights into the mechanism of cardiac resynchronization therapy (CRT). This review addresses the validity, reliability, and overall feasibility of ECGi for use in a diverse range of arrhythmias. A systematic search limited to full-text human studies published in peer-reviewed journals was performed through Medline via PubMed, using various combinations of three key concepts: ECGi, arrhythmia, and CRT. A total of 456 studies were screened through titles and abstracts. Ultimately, 42 studies were included for literature review. Evidence to date suggests that ECGi can be used to provide diagnostic insights regarding the mechanistic basis of arrhythmias and the location of arrhythmia origin. Furthermore, ECGi can yield valuable information to guide therapeutic decision-making, including during CRT. Several studies have used ECGi as a diagnostic tool for atrial and ventricular arrhythmias. More recently, studies have tested the value of this technique in predicting outcomes of CRT. As a non-invasive method for assessing cardiovascular disease, particularly arrhythmias, ECGi represents a significant advancement over standard procedures in contemporary cardiology. Its full potential has yet to be fully explored.

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

Europace: 04 Aug 2020; epub ahead of print
Pereira H, Niederer S, Rinaldi CA
Europace: 04 Aug 2020; epub ahead of print | PMID: 32754737
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Abstract

Randomized study defining the optimum target interlesion distance in ablation index-guided atrial fibrillation ablation.

Hoffmann P, Diaz Ramirez I, Baldenhofer G, Stangl K, Mont L, Althoff TF
Aims
While the CLOSE protocol proposes a maximally tolerable interlesion distance (ILD) of 6 mm for ablation index ablation index-guided atrial fibrillation (AF) ablation, a target ILD has never been defined. This randomized study sought to establish a target ILD for ablation index-guided AF ablation.
Methods and results
Consecutive patients scheduled for first-time pulmonary vein (PV) isolation (PVI) were randomly assigned to ablation protocols with a target ILD of 5.0-6.0 mm or 3.0-4.0 mm, with the primary endpoint of first-pass PVI. In compliance with the CLOSE protocol, the maximum tolerated ILD was 6.0 mm in both study protocols. A target ablation index of ≥550 (anterior) or ≥400 (posterior) was defined for the \'5-6 mm\' protocol and ≥500 (anterior) or ≥350 (posterior) for the \'3-4 mm\' protocol. The study was terminated early for superiority of the \'3-4 mm\' protocol. Forty-two consecutive patients were randomized and 84 ipsilateral PV pairs encircled according to the study protocol. First-pass PVI was accomplished in 35.0% of the \'5-6 mm\' group and 90.9% of the \'3-4 mm\' group (P < 0.0001). Median ILD was 5.2 mm in the \'5-6 mm\' group and 3.6 mm in the \'3-4 mm\' group (P < 0.0001). In line with the distinct ablation index targets, median ablation index was lower in the \'3-4 mm\' group (416 vs. 452, P < 0.0001). While mean procedure time was shorter in the \'3-4 mm\' group (149 ± 27 vs. 167 ± 33min, P = 0.004), fluoroscopy times did not differ significantly (4.7 ± 2.2 vs. 5.1 ± 1.8 min, P = 0.565).
Conclusion
In ablation index-guided AF ablation, an ILD of 3.0-4.0 mm should be targeted rather than 5.0-6.0 mm. Moreover, the lower target ILD may allow for less extensive ablation at each given point.

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

Europace: 29 Jul 2020; epub ahead of print
Hoffmann P, Diaz Ramirez I, Baldenhofer G, Stangl K, Mont L, Althoff TF
Europace: 29 Jul 2020; epub ahead of print | PMID: 32729896
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Abstract

Predictors of recurrence of atrial fibrillation within the first 3 months after ablation.

Zink MD, Chua W, Zeemering S, di Biase L, ... Kirchhof P, Schotten U
Aims
Freedom from atrial fibrillation (AF) at 1 year can be achieved in 50-70% of patients undergoing catheter ablation. Recurrent AF early after ablation most commonly terminates spontaneously without further interventional treatment but is associated with later recurrent AF. The aim of this investigation is to identify clinical and procedural factors associated with recurrence of AF early after ablation.
Methods and results
We retrospectively analysed data for recurrence of AF within the first 3 months after catheter ablation from the randomized controlled AXAFA-AFNET 5 trial, which demonstrated that continuous anticoagulation with apixaban is as safe and as effective compared to vitamin K antagonists in 678 patients undergoing first AF ablation. The primary outcome of first recurrent AF within 90 days was observed in 163 (28%) patients, in which 78 (48%) patients experienced an event within the first 14 days post-ablation. After multivariable adjustment, a history of stroke/transient ischaemic attack [hazard ratio (HR) 1.54, 95% confidence interval (CI) 0.93-2.6; P = 0.11], coronary artery disease (HR 1.85, 95% CI 1.20-2.86; P = 0.005), cardioversion during ablation (HR 1.78, 95% CI 1.26-2.49; P = 0.001), and an age:sex interaction for older women (HR 1.01, 95% CI 1.00-1.01; P = 0.04) were associated with recurrent AF. The P-wave duration at follow-up was significantly longer for patients with AF recurrence (129 ± 31 ms vs. 122 ± 22 ms in patients without AF, P = 0.03).
Conclusion
Half of all early AF recurrences within the first 3 months post-ablation occurred within the first 14 days post-ablation. Vascular disease and cardioversion during the procedure are strong predictors of recurrent AF. P-wave duration at follow-up was longer in patients with recurrent AF.
Trial registration
Clinicaltrials.gov identifier NCT02227550, https://clinicaltrials.gov/ct2/show/NCT02227550?term=NCT02227550.&rank=1.

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

Europace: 27 Jul 2020; epub ahead of print
Zink MD, Chua W, Zeemering S, di Biase L, ... Kirchhof P, Schotten U
Europace: 27 Jul 2020; epub ahead of print | PMID: 32725107
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Abstract

Remote monitoring of cardiac implanted electronic devices: legal requirements and ethical principles - ESC Regulatory Affairs Committee/EHRA joint task force report.

Nielsen JC, Kautzner J, Casado-Arroyo R, Burri H, ... Heidbuchel H, Fraser AG

The European Union (EU) General Data Protection Regulation (GDPR) imposes legal responsibilities concerning the collection and processing of personal information from individuals who live in the EU. It has particular implications for the remote monitoring of cardiac implantable electronic devices (CIEDs). This report from a joint Task Force of the European Heart Rhythm Association and the Regulatory Affairs Committee of the European Society of Cardiology (ESC) recommends a common legal interpretation of the GDPR. Manufacturers and hospitals should be designated as joint controllers of the data collected by remote monitoring (depending upon the system architecture) and they should have a mutual contract in place that defines their respective roles; a generic template is proposed. Alternatively, they may be two independent controllers. Self-employed cardiologists also are data controllers. Third-party providers of monitoring platforms may act as data processors. Manufacturers should always collect and process the minimum amount of identifiable data necessary, and wherever feasible have access only to pseudonymized data. Cybersecurity vulnerabilities have been reported concerning the security of transmission of data between a patient\'s device and the transceiver, so manufacturers should use secure communication protocols. Patients need to be informed how their remotely monitored data will be handled and used, and their informed consent should be sought before their device is implanted. Review of consent forms in current use revealed great variability in length and content, and sometimes very technical language; therefore, a standard information sheet and generic consent form are proposed. Cardiologists who care for patients with CIEDs that are remotely monitored should be aware of these issues.

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

Europace: 28 Jul 2020; epub ahead of print
Nielsen JC, Kautzner J, Casado-Arroyo R, Burri H, ... Heidbuchel H, Fraser AG
Europace: 28 Jul 2020; epub ahead of print | PMID: 32725140
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Abstract

The prognostic value of soluble suppression of tumourigenicity 2 and galectin-3 for sinus rhythm maintenance after cardioversion due to persistent atrial fibrillation in patients with normal left ventricular systolic function.

Wałek P, Gorczyca I, Grabowska U, Spałek M, Wożakowska-Kapłon B
Aims
Soluble suppression of tumourigenicity 2 (sST2) and galectin-3 are involved in cardiac fibrosis, inflammation, and remodelling. However, the place of sST2 and galectin-3 in predicting the outcomes of electrical cardioversion of atrial fibrillation (AF) is uncertain. We evaluated whether these biomarkers could predict sinus rhythm (SR) maintenance after cardioversion of persistent AF in patients with normal left ventricular systolic function.
Methods and results
The study included 80 patients with persistent AF, who underwent cardioversion from February 2016 to August 2018. The blood concentrations of sST-2 and galectin-3 were measured with ELISA and the ASPECT-PLUS assays. Clinical and electrocardiographic follow-up was performed at months 1, 6, and 12. Patients who maintained SR at 12 months had significantly lower concentrations of sST2, measured by ELISA and ASPECT-PLUS assays, than the remaining patients (16.9 ± 9.8 vs. 28 ± 22.9 ng/mL; P < 0.001; 28.7 ± 13.4 vs. 40 ± 25.1 ng/mL; P = 0.003); the concentration of galectin-3 did not differ between these patients. Multivariable logistic regression showed that log-transformed sST2 ELISA was a significant predictor of SR maintenance at 12 months [odds ratio 0.14; 95% confidence interval (CI) 0.03-0.58; P = 0.006]. On receiver-operating characteristic curve analysis, the areas under the curve for the concentration of sST2 was 0.752 (95% CI 0.634-0.870; P < 0.001). The concentrations of sST2 measured with the two assays were strongly correlated (rho = 0.8; CI 95% 0.7-0.87; P = 0.001).
Conclusion
Soluble suppression of tumourigenicity 2, but not galectin-3, can be used to predict SR maintenance after cardioversion of AF in patients with normal left ventricular systolic function. The measurements of sST2 concentrations with the rapid lateral flow and enzyme-linked immunoassays were consistent.

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

Europace: 04 Aug 2020; epub ahead of print
Wałek P, Gorczyca I, Grabowska U, Spałek M, Wożakowska-Kapłon B
Europace: 04 Aug 2020; epub ahead of print | PMID: 32754725
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Abstract

Management of thrombus formation after electrical isolation of the left atrial appendage in patients with atrial fibrillation.

Fink T, Ouyang F, Heeger CH, Sciacca V, ... Tilz RR, Vogler J
Aims
Left atrial appendage (LAA) electrical isolation (LAAEI) in addition to pulmonary vein isolation is an emerging catheter-based therapy to treat symptomatic atrial fibrillation. Previous studies found high incidences of LAA thrombus formation after LAAEI. This study sought to analyse therapeutic strategies aiming at the resolution of LAA thrombi and prevention of thromboembolism.
Methods and results
Left atrial appendage electrical isolation was conducted via creation of left atrial linear lesions or cryoballoon ablation. Follow-up including transoesophageal echocardiography was conducted. In patients with LAA thrombus, oral anticoagulation (OAC) was adjusted until thrombus resolution was documented. Percutaneous LAA closure (LAAC) under use of a cerebral protection device was conducted in case of medically refractory LAA thrombi. Left atrial appendage thrombus was documented in 54 of 239 analysed patients who had undergone LAAEI. Thrombus resolution was documented in 39/51 patients (72.2%) with available follow-up after adjustment of OAC. Twenty-nine patients underwent LAAC and 10 patients were kept on OAC after LAAEI. No thromboembolic events or further LAA thrombi were documented after 553 ± 443 days of follow-up in these patients. Persistent LAA thrombi despite adaption of OAC was documented in 12/51 patients. One patient remained on OAC until the end of follow-up, while LAAC with a cerebral protection device was performed in 11 patients in the presence of LAA thrombus without complications.
Conclusion
Left atrial appendage thrombus formation is common after LAAEI. Adjustment of OAC leads to LAA thrombus resolution in most patients. Left atrial appendage closure in the presence of LAA thrombi might be a feasible option in case of failed medical treatment.

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

Europace: 02 Aug 2020; epub ahead of print
Fink T, Ouyang F, Heeger CH, Sciacca V, ... Tilz RR, Vogler J
Europace: 02 Aug 2020; epub ahead of print | PMID: 32743641
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Abstract

Repolarization instability and arrhythmia by IKr block in single human-induced pluripotent stem cell-derived cardiomyocytes and 2D monolayers.

Altrocchi C, de Korte T, Bernardi J, Spätjens RLHMG, ... Zaza A, Volders PGA
Aims
Human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) have proven valuable for studies in drug discovery and safety, although limitations regarding their structural and electrophysiological characteristics persist. In this study, we investigated the electrophysiological properties of Pluricyte® CMs, a commercially available hiPSC-CMs line with a ventricular phenotype, and assessed arrhythmia incidence by IKr block at the single-cell and 2D monolayer level.
Methods and results
Action potentials were measured at different pacing frequencies, using dynamic clamp. Through voltage-clamp experiments, we determined the properties of INa, IKr, and ICaL. Intracellular Ca2+ measurements included Ca2+-transients at baseline and during caffeine perfusion. Effects of IKr block were assessed in single hiPSC-CMs and 2D monolayers (multi-electrode arrays). Action-potential duration (APD) and its rate dependence in Pluricyte® CMs were comparable to those reported for native human CMs. INa, IKr, and ICaL revealed amplitudes, kinetics, and voltage dependence of activation/inactivation similar to other hiPSC-CM lines and, to some extent, to native CMs. Near-physiological Ca2+-induced Ca2+ release, response to caffeine and excitation-contraction coupling gain characterized the cellular Ca2+-handling. Dofetilide prolonged the APD and field-potential duration, and induced early afterdepolarizations. Beat-to-beat variability of repolarization duration increased significantly before the first arrhythmic events in single Pluricyte® CMs and 2D monolayers, and predicted pending arrhythmias better than action-potential prolongation.
Conclusion
Taking their ion-current characteristics and Ca2+ handling into account, Pluricyte® CMs are suitable for in vitro studies on action potentials and field potentials. Beat-to-beat variability of repolarization duration proved useful to evaluate the dynamics of repolarization instability and demonstrated its significance as proarrhythmic marker in hiPSC-CMs during IKr block.

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

Europace: 07 Aug 2020; epub ahead of print
Altrocchi C, de Korte T, Bernardi J, Spätjens RLHMG, ... Zaza A, Volders PGA
Europace: 07 Aug 2020; epub ahead of print | PMID: 32770183
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Abstract

Long-term outcome of patients with invasive electrophysiology procedure-related cardiac tamponade.

von Olshausen G, Bourke T, Schwieler J, Drca N, ... Jensen-Urstad M, Braunschweig F
Aims
Iatrogenic cardiac tamponades are a rare but dreaded complication of invasive electrophysiology procedures (EPs). Their long-term impact on clinical outcomes is unknown. This study analysed the risk of death or serious cardiovascular events in patients suffering from EP-related cardiac tamponade requiring pericardiocentesis during long-term follow-up.
Methods and results
Out of 19 997 invasive EPs at the Karolinska University Hospital between January 1998 and September 2018, all patients with EP-related periprocedural cardiac tamponade were identified (n = 60) and matched (1:3 ratio) to a control group (n = 180). After a follow-up of 5 years, the composite primary endpoint - death from any cause, acute myocardial infarction, transitory ischaemic attack (TIA)/stroke, and hospitalization for heart failure - occurred in significantly more patients in the tamponade than in the control group [12 patients (20.0%) vs. 19 patients (10.6%); hazard ratio (HR) 2.53 (95% confidence interval, CI 1.15-5.58); P = 0.021]. This was mainly driven by a higher incidence of TIA/stroke in the tamponade than in the control group [HR 3.75 (95% CI 1.01-13.97); P = 0.049]. Death from any cause, acute myocardial infarction, and hospitalization for heart failure did not show a significant difference between the groups. Hospitalization for pericarditis occurred in significantly more patients in the tamponade than in the control group [HR 36.0 (95% CI 4.68-276.86); P = 0.001].
Conclusion
Patients with EP-related cardiac tamponade are at higher risk for cerebrovascular events during the first 2 weeks and hospitalization for pericarditis during the first months after index procedure. Despite the increased risk for early complications tamponade patients have a good long-term prognosis without increased risk for mortality or other serious cardiovascular events.

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

Europace: 08 Aug 2020; epub ahead of print
von Olshausen G, Bourke T, Schwieler J, Drca N, ... Jensen-Urstad M, Braunschweig F
Europace: 08 Aug 2020; epub ahead of print | PMID: 32772100
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Abstract

Periprocedural, early, and long-term risks of pacemaker implantation after atrioventricular nodal re-entry tachycardia ablation: a French nationwide cohort.

Decroocq M, Rousselet L, Riant M, Norberciak L, ... Germain M, Menet A
Aims
Pacemaker implantation (PI) after atrioventricular nodal re-entry tachycardia (AVNRT) ablation is a dreadful complication. We aimed to assess periprocedural, early, and late risks for PI.
Methods and results
All 27 022 patients who underwent latest AVNRT ablation in France from 2009 to 2017, were identified in the nationwide medicalization database. A control group of 305 152 patients hospitalized for arm, leg, or skin injuries with no history of AVNRT or supraventricular tachycardia were selected. After propensity score matching, both groups had mean age of 53 ± 18 years and were predominantly female (64%). During this 9-year period, 822 of 27 022 (3.0%) AVNRT patients underwent PI, with significant higher risk in propensity-matched AVNRT patients compared to propensity-matched controls [2.9% vs. 0.9%; hazard ratio 3.4 (2.9-3.9), P < 0.0001]. This excess risk was significant during all follow-up, including periprocedural (1st month), early (1-6 months), and late (>6 months) risk periods. Annualized late risk per 100 AVNRT patients was 0.2%. In comparison to controls, excess risk was 0.2% in <30-year-old AVNRT patients; 0.7% in 30-50-year-old; 1.1% in 50-70-year-old and 6.5% over 70-year-olds. Risk for PI was also significantly different according to three procedural factors: centres, experience, and ablation date, with a 30% decrease since 2015.
Conclusion
Periprocedural, early, and late risks for PI were higher after AVNRT ablation compared to propensity-matched controls. Longer follow-up is needed as the excess risk seems to persist late after AVNRT ablation.

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

Europace: 11 Aug 2020; epub ahead of print
Decroocq M, Rousselet L, Riant M, Norberciak L, ... Germain M, Menet A
Europace: 11 Aug 2020; epub ahead of print | PMID: 32785702
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Abstract

Functional modulation of atrio-ventricular conduction by enhanced late sodium current and calcium-dependent mechanisms in Scn5a1798insD/+ mice.

Rivaud MR, Marchal GA, Wolswinkel R, Jansen JA, ... Bezzina CR, Remme CA
Aims
SCN5A mutations are associated with arrhythmia syndromes, including Brugada syndrome, long QT syndrome type 3 (LQT3), and cardiac conduction disease. Long QT syndrome type 3 patients display atrio-ventricular (AV) conduction slowing which may contribute to arrhythmogenesis. We here investigated the as yet unknown underlying mechanisms.
Methods and results
We assessed electrophysiological and molecular alterations underlying AV-conduction abnormalities in mice carrying the Scn5a1798insD/+ mutation. Langendorff-perfused Scn5a1798insD/+ hearts showed prolonged AV-conduction compared to wild type (WT) without changes in atrial and His-ventricular (HV) conduction. The late sodium current (INa,L) inhibitor ranolazine (RAN) normalized AV-conduction in Scn5a1798insD/+ mice, likely by preventing the mutation-induced increase in intracellular sodium ([Na+]i) and calcium ([Ca2+]i) concentrations. Indeed, further enhancement of [Na+]i and [Ca2+]i by the Na+/K+-ATPase inhibitor ouabain caused excessive increase in AV-conduction time in Scn5a1798insD/+ hearts. Scn5a1798insD/+ mice from the 129P2 strain displayed more severe AV-conduction abnormalities than FVB/N-Scn5a1798insD/+ mice, in line with their larger mutation-induced INa,L. Transverse aortic constriction (TAC) caused excessive prolongation of AV-conduction in FVB/N-Scn5a1798insD/+ mice (while HV-intervals remained unchanged), which was prevented by chronic RAN treatment. Scn5a1798insD/+-TAC hearts showed decreased mRNA levels of conduction genes in the AV-nodal region, but no structural changes in the AV-node or His bundle. In Scn5a1798insD/+-TAC mice deficient for the transcription factor Nfatc2 (effector of the calcium-calcineurin pathway), AV-conduction and conduction gene expression were restored to WT levels.
Conclusions
Our findings indicate a detrimental role for enhanced INa,L and consequent calcium dysregulation on AV-conduction in Scn5a1798insD/+ mice, providing evidence for a functional mechanism underlying AV-conduction disturbances secondary to gain-of-function SCN5A mutations.

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

Europace: 09 Aug 2020; epub ahead of print
Rivaud MR, Marchal GA, Wolswinkel R, Jansen JA, ... Bezzina CR, Remme CA
Europace: 09 Aug 2020; epub ahead of print | PMID: 32778883
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Abstract

Prescription of oral anticoagulants and antiplatelets for stroke prophylaxis in atrial fibrillation: nationwide time series ecological analysis.

Wu J, Alsaeed ES, Barrett J, Hall M, Cowan C, Gale CP
Aims
To investigate trends in the prescription of oral anticoagulants (OACs) and antiplatelet agents for atrial fibrillation (AF).
Methods and results
Prescription data for 450 518 patients with AF from 3352 General Practices in England, was obtained from the GRASP-AF registry, 2009-2018. Annualized temporal trends for OAC and antiplatelet prescription were reported according to eligibility based on stroke risk (CHADS2 or CHA2DS2-VASc scores ≥1 or >2, respectively). From 2009 to 2018, the prevalence of AF increased from 1.6% [95% confidence interval (CI) 1.5-1.7%] to 2.4% (2.3-2.5%), and for those with AF the proportion prescribed OAC increased from 47.6% to 75.0% (P-trend < 0.001; relative risk 1.57, 95% CI 1.55-1.60) and for antiplatelet decreased from 37.4% to 9.2% (P-trend < 0.001). In early-years (2009-2013), eligible patients aged ≥80 years were less likely to be prescribed OAC than patients aged <80 years [odds ratio (OR) 0.55, 95% CI 0.51-0.59 for CHADS2≥1 in 2009] (all P-trends < 0.001). This \'OAC prescription gap\' reduced over the study period (OR 0.93, 0.90-0.96 in 2018). Whilst the prescription of direct oral anticoagulant (DOAC) as a proportion of all OAC increased from 0.1% (95% CI 0.0-0.2%) in 2011 to 58.8% (58.4-59.2%) in 2018, it was inversely associated with patient age (P-trend < 0.001) and their risk of stroke.
Conclusion
Between 2009 and 2018, in England, the use of OAC for stroke prophylaxis in AF increased, with DOAC accounting for over half of OAC uptake in 2018. Despite a reduction in the OAC-prescription gap, a new paradox exists relating to DOAC prescription for the elderly and those at higher risk of stroke.

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

Europace: 09 Aug 2020; epub ahead of print
Wu J, Alsaeed ES, Barrett J, Hall M, Cowan C, Gale CP
Europace: 09 Aug 2020; epub ahead of print | PMID: 32778878
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Abstract

Novel electroanatomical map for permanent his bundle pacing: the Mont Blanc approach - influence of the learning curve and procedural outcome.

Imnadze G, Vijayaraman P, Bante H, Eitz T, ... Sohns C, Sommer P
Aims
Pacing the specific conduction system like the Bundle of His (HB) can lead to more physiologic activation patterns compared to traditional right ventricular apical pacing. The aim of this study was to estimate the feasibility and value of electroanatomical mapping (EAM) for HB pacing during the learning curve and its impact on procedural outcome.
Methods and results
Fifteen consecutive patients were treated using EAM of the His bundle region before implantation. Voltage and activation maps of HB potentials were performed. The activation time from His potential to R wave (ECG-reference) was measured and correlated to the HV interval. The atrial and ventricular potentials were blended so the active window could only see the His potential. After completing the activation map, it was transformed into a peak-to-peak voltage map of the HB. With reversed black and white colour scale, the exact point of the maximal His signal amplitude was visualized. Procedural data for the implantation were analysed using this innovative approach. The average total procedural time and fluoroscopy time was 88.2 ± 19.1 min and 10.9 ± 4.5 min, respectively. The 3D mapping time was 18.4 ± 5.1 min. The 13.9 ± 5.1 His potential points were needed in average to complete the map. No periprocedural complications were seen in this cohort. In 86.7% of cases, His bundle pacing was successful. The average threshold for the His bundle stimulation and the R-wave amplitude was 1.62 ± 1 V (@1.0 ms) and 4.8 ± 3.2 mV, respectively. The pacing impedance was 513.5 ± 102.8 Ω. Average paced QRS complex width was 116.9 ± 20.3ms. On average 2.6 ± 1.6 lead positions were targeted to find the optimal pacing site.
Conclusion
Electroanatomical mapping-guided implantation of His-bundle leads can facilitate the identification of optimal pacing sites and allow to minimize procedure and fluoroscopy times even during the phase of the learning curve.

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

Europace: 09 Aug 2020; epub ahead of print
Imnadze G, Vijayaraman P, Bante H, Eitz T, ... Sohns C, Sommer P
Europace: 09 Aug 2020; epub ahead of print | PMID: 32778877
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Abstract

Selective optogenetic stimulation of fibroblasts enables quantification of hetero-cellular coupling to cardiomyocytes in a three-dimensional model of heart tissue.

Funken M, Bruegmann T, Sasse P
Aims
Besides providing mechanical stability, fibroblasts in the heart could modulate the electrical properties of cardiomyocytes. Here, we aim to develop a three-dimensional hetero-cellular model to analyse the electric interaction between fibroblasts and human cardiomyocytes in vitro using selective optogenetic de- or hyperpolarization of fibroblasts.
Methods and results
NIH3T3 cell lines expressing the light-sensitive ion channel Channelrhodopsin2 or the light-induced proton pump Archaerhodopsin were generated for optogenetic depolarization or hyperpolarization, respectively, and characterized by patch clamp. Cardiac bodies consisting of 50% fibroblasts and 50% human pluripotent stem cell-derived cardiomyocytes were analysed by video microscopy and membrane potential was measured with sharp electrodes. Myofibroblast activation in cardiac bodies was enhanced by transforming growth factor-β1 (TGF-β1)-stimulation. Connexin-43 expression was analysed by qPCR and fluorescence recovery after photobleaching. Illumination of Channelrhodopsin2 or Archaerhodopsin expressing fibroblasts induced inward currents and depolarization or outward currents and hyperpolarization. Transforming growth factor-β1-stimulation elevated connexin-43 expression and increased cell-cell coupling between fibroblasts as well as increased basal beating frequency and cardiomyocyte resting membrane potential in cardiac bodies. Illumination of cardiac bodies generated with Channelrhodopsin2 fibroblasts accelerated spontaneous beating, especially after TGF-β1-stimulation. Illumination of cardiac bodies prepared with Archaerhodopsin expressing fibroblasts led to hyperpolarization of cardiomyocytes and complete block of spontaneous beating after TGF-β1-stimulation. Effects of light were significantly smaller without TGF-β1-stimulation.
Conclusion
Transforming growth factor-β1-stimulation leads to increased hetero-cellular coupling and optogenetic hyperpolarization of fibroblasts reduces TGF-β1 induced effects on cardiomyocyte spontaneous activity. Optogenetic membrane potential manipulation selectively in fibroblasts in a new hetero-cellular cardiac body model allows direct quantification of fibroblast-cardiomyocyte coupling in vitro.

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

Europace: 17 Aug 2020; epub ahead of print
Funken M, Bruegmann T, Sasse P
Europace: 17 Aug 2020; epub ahead of print | PMID: 32808019
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Abstract

Efficacy of high-power and short-duration ablation in patients with atrial fibrillation: a prospective randomized controlled trial.

Shin DG, Ahn J, Han SJ, Lim HE
Aims
The formation of radiofrequency lesions depends on the power and duration of ablation, and the contact force (CF). Although high power (HP) creates continuous and transmural lesions, most centres still use 25-30 W for 30-40 s for safety reasons. We evaluated the clinical efficacy and safety of a HP and short-duration (HPSD) strategy for atrial fibrillation (AF) ablation.
Methods and results
One hundred and fifty patients [58.2 ± 10.0 years, 48% with paroxysmal AF (PAF)] scheduled for index AF ablation using a CF-sensing catheter were randomly assigned to three groups [30 W, 40 W, and 50 W at ablation sites of anterior, roof, and inferior segments of pulmonary vein (PV) antra and roof line between each upper PV]. In 25-30 W for ≤20 s was applied at posterior wall ablation site in all subjects. Compared with the 30 W and 40 W groups, procedure (P < 0.001) and ablation times (P < 0.001) were shorter and ablation number for PV isolation (P < 0.001) was smaller in the 50 W group. There were no significant differences in the CF and ablation index (AI) among the three groups. There were no significant differences in the procedure-related complication rates. During the 12-month follow-up, AF recurred in 24 (16%) patients with no significant difference among the groups (P = 0.769). In the multivariate analysis, non-PAF [hazard ratio (HR) 2.836, P = 0.045] and AI (HR 0.983, P = 0.001) were independent risk factors for AF recurrence.
Conclusion
Radiofrequency ablation with HPSD is a safe and effective strategy with reduced ablation number and shortened procedure time compared to conventional ablation.

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

Europace: 17 Aug 2020; epub ahead of print
Shin DG, Ahn J, Han SJ, Lim HE
Europace: 17 Aug 2020; epub ahead of print | PMID: 32810203
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Impact:
Abstract

Oesophageal Probe Evaluation in Radiofrequency Ablation of Atrial Fibrillation (OPERA): results from a prospective randomized trial.

Schoene K, Arya A, Grashoff F, Knopp H, ... Zachäus M, Sommer P
Aims
The aim of the study was to determine the incidence of oesophageal lesions after radiofrequency ablation (RFA) of atrial fibrillation (AF) with or without the use of oesophageal temperature probes.
Methods and results
Two hundred patients were prospectively randomized into two groups: the OPERA+ group underwent RFA using oesophageal probes (SensiTherm™); the OPERA- group received RFA using fixed energy levels of 25 W at the posterior wall without an oesophageal probe. All patients underwent post-interventional endoscopy and Holter-electrocardiogram after 6 months. (Clinical.Trials.gov: NCT03246594). One hundred patients were randomized in OPERA+ and 100 patients in OPERA-. The drop-out rate was 10%. In total, 18/180 (10%) patients developed endoscopically diagnosed oesophageal lesions (EDEL). There was no difference between the groups with 10/90 (11%) EDEL in OPERA+ vs. 8/90 (9%) in OPERA- (P = 0.62). Despite the higher power delivered at the posterior wall in OPERA+ [28 ± 4 vs. 25 ± 2 W (P = 0.001)], the average EDEL size was equal [5.7 ± 2.6 vs. 4.5 ± 1.7 mm (P = 0.38)]. The peak temperature did not correlate with EDEL size. During follow-up, no patient died. Only one patient in OPERA- required a specific therapy for treatment of the lesion. Cumulative AF recurrence after 6 (3-13) months was 28/87 (32%) vs. 34/88 (39%), P = 0.541.
Conclusion
This first randomized study demonstrates that intraoesophageal temperature monitoring using the SensiTherm™ probe does not affect the probability of developing EDEL. The peak temperature measured by the thermoprobe seems not to correlate with the incidence of EDEL. Empiric energy reduction at the posterior wall did not affect the efficacy of the procedure.

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

Europace: 20 Aug 2020; epub ahead of print
Schoene K, Arya A, Grashoff F, Knopp H, ... Zachäus M, Sommer P
Europace: 20 Aug 2020; epub ahead of print | PMID: 32820324
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Impact:
Abstract

Mobile health applications for managing atrial fibrillation for healthcare professionals and patients: a systematic review.

Lane DA, McMahon N, Gibson J, Weldon JC, ... Caiani EG, Potpara TS
Aims
A plethora of mobile health applications (m-health apps) to support healthcare are available for both patients and healthcare professionals (HCPs) but content and quality vary considerably and few have undergone formal assessment. The aim is to systematically review the literature on m-health apps for managing atrial fibrillation (AF) that examine the impact on knowledge of AF, patient and HCP behaviour, patients\' quality-of-life, and user engagement.
Methods and results
MEDLINE, EMBASE, CINAHL, and PsychInfo were searched from 1 January 2005 to 5 September 2019, with hand-searching of clinical trial registers and grey literature. Studies were eligible for inclusion if they reported changes in any of the following: (i) knowledge of AF; (ii) provider behaviour (e.g. guideline adherence); (iii) patient behaviour (e.g. medication adherence); (iv) patient quality-of-life; and (v) user engagement. Two reviewers independently assessed articles for eligibility. A narrative review was undertaken as included studies varied widely in their design, interventions, comparators, and outcomes. Seven studies were included; six m-health apps aimed at patients and one at HCPs. Mobile health apps ranged widely in design, features, and method of delivery. Four studies reported patient knowledge of AF; three demonstrated significant knowledge improvement post-intervention or compared to usual care. One study reported greater HCP adherence to oral anticoagulation guidelines after m-health app implementation. Two studies reported on patient medication adherence and quality-of-life; both showed improved quality-of-life post-intervention but only one observed increased adherence. Regarding user engagement, five studies reported patient perspectives on usability, three on acceptability, and one on feasibility; overall all m-health apps were rated positively.
Conclusion
Mobile health apps demonstrate improvements in patient knowledge, behaviour, and quality of life. Studies formally evaluating the impact of m-health on HCP behaviour are scarce and larger-scale studies with representative patient cohorts, appropriate comparators, and longer-term assessment of the impact of m-health apps are warranted.

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

Europace: 26 Aug 2020; epub ahead of print
Lane DA, McMahon N, Gibson J, Weldon JC, ... Caiani EG, Potpara TS
Europace: 26 Aug 2020; epub ahead of print | PMID: 32853369
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Impact:
Abstract

Predictors of long-term mortality after catheter ablation of ventricular tachycardia in a contemporary cohort of patients with structural heart disease.

Darma A, Bertagnolli L, Dinov B, Torri F, ... Hindricks G, Arya A
Aims
Ablation of ventricular tachycardias (VTs) in patients with structural heart disease has been established in the past decades as an effective and safe treatment. However, the prognosis and long-term outcome remains poor.
Methods and results
We investigated 309 patients with ischaemic cardiomyopathy (ICM) and non-ischaemic cardiomyopathy (NICM) (186 ICM, 123 NICM; 271 males; mean age 64.1 ± 12 years; ejection fraction 34 ± 13%) after ≥1 VT ablations over a mean follow-up period of 34 ± 28 months. Electrical storm was the indication for 224 patients (73%), whereas 86 patients (28%) underwent epicardial as well as endocardial ablation. During follow-up, 132 patients (43%) experienced VT recurrence and 97 (31%) died. Ischaemic cardiomyopathy and NICM patients showed comparable results, regarding procedural endpoints, complications, VT recurrence and survival. The Cox-regression analysis for all-cause mortality revealed that the presence of higher left ventricular end-diastolic volume (LVEDV; P < 0.001), male gender (P = 0.018), atrial fibrillation (AF; P < 0.001), chronic obstructive pulmonary disease (COPD; P = 0.001), antiarrhythmic drugs during the follow-up (P < 0.001), polymorphic VTs (P = 0.028), and periprocedural complications (P = 0.001) were independent predictors of mortality.
Conclusion
Ischaemic cardiomyopathy and NICM patients undergoing VT ablation had comparable results regarding procedural endpoints, complications, VT recurrence and 3-year mortality. Higher LVEDV, male gender, COPD, AF, polymorphic VTs, use of antiarrhythmics, and periprocedural complications are strong and independent predictors for increased mortality. The PAINESD score accurately predicted the long-term outcome in our cohort.

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

Europace: 22 Aug 2020; epub ahead of print
Darma A, Bertagnolli L, Dinov B, Torri F, ... Hindricks G, Arya A
Europace: 22 Aug 2020; epub ahead of print | PMID: 32830252
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Impact:
Abstract

The combined novel KCNQ1 frameshift I145Sfs*92 and nonsense W392X variants caused Jervell and Lange-Nielsen syndrome in a Chinese infant presenting with sustained foetal bradycardia.

Zhang Y, Li X, Yang Y, Wang J, Gao X, Fan M
Aims
We report clinical and molecular analysis of an infant presenting with foetal bradycardia and clinical outcome of Jervell and Lange-Nielsen syndrome (JLNS).
Methods and results
Clinical, electrocardiogram (ECG), and echocardiographic data were collected from members in a three-generation family. Whole exomes were amplified and sequenced for proband. The identified variants were verified in the remaining members. The pathogenicity of candidate variants was predicted using multiple software programmes. A 28-year-old non-consanguineous Chinese woman at 23 weeks\' gestation presenting with sustained foetal bradycardia of 100 b.p.m. Immunological disorders and infection were excluded. The infant was delivered at 37 weeks\' gestation with 2700-g birthweight. QTc was prolonged in both ECG and Holter recording. Hearing tests confirmed bilateral sensorineural hearing loss. Genetic testing demonstrated that the infant carried a novel frameshift c.431delC (p.I145Sfs*92) and a novel nonsense c.1175G>A (p.W392X) compound variants of KCNQ1 inherited from mother and father, respectively, in autosomal recessive inheritance. Only relative II-5 carrying heterozygous KCNQ1-I145Sfs*92 variant had prolonged QTc, while the other carriers did not have prolonged QT, suggesting an autosomal dominant inheritance of LQT1 phenotype with incomplete penetrance in the family.
Conclusion
We report the novel frameshift KCNQ1-I145Sfs*92 and nonsense KCNQ1-W392X compound variants in autosomal recessive inheritance that caused JLNS presenting as sustained foetal bradycardia for the first time. Meanwhile, KCNQ1-I145Sfs*92 heterozygous variant demonstrated LQT1 phenotype in autosomal dominant inheritance with incomplete penetrance.

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

Europace: 22 Aug 2020; epub ahead of print
Zhang Y, Li X, Yang Y, Wang J, Gao X, Fan M
Europace: 22 Aug 2020; epub ahead of print | PMID: 32830254
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Impact:
Abstract

Arrhythmia exacerbation after post-infarction ventricular tachycardia ablation: prevalence and prognostic significance.

Siontis KC, Kim HM, Vergara P, Peretto G, ... Morady F, Bogun FM
Aims 
Catheter ablation is an effective treatment for post-infarction ventricular tachycardia (VT). However, some patients may experience a worsened arrhythmia phenotype after ablation. We aimed to determine the prevalence and prognostic impact of arrhythmia exacerbation (AE) after post-infarction VT ablation.
Methods and results 
A total of 1187 consecutive patients (93% men, median age 68 years, median ejection fraction 30%) who underwent post-infarction VT ablation at six centres were included. Arrhythmia exacerbation was defined as post-ablation VT storm or incessant VT in patients without prior similar events. During follow-up (median 717 days), 426 (36%) patients experienced VT recurrence. Events qualifying as AE occurred in 67 patients (6%). Median times to VT recurrence with and without AE were 238 [interquartile range (IQR) 35-640] days and 135 (IQR 22-521) days, respectively (P = 0.25). Almost half of the patients (46%) who experienced AE experienced it within 6 months of the index procedure. Patients with AE had had longer ablation times during the ablation procedures compared to the rest of the patients (median 42 vs. 34 min, P = 0.02). Among patients with VT recurrence, the risk of death or heart transplantation was significantly higher in patients with than without AE (hazard ratio 1.99, 95% CI 1.28-3.10; P = 0.002) after adjusting for age, gender, ejection fraction, cardiac resynchronization therapy, post-ablation non-inducibility, and post-ablation amiodarone use.
Conclusion 
Arrhythmia exacerbation after ablation of infarct-related VT is infrequent but is independently associated with an adverse long-term outcome among patients who experience a VT recurrence. The mechanisms and mitigation strategies of AE after catheter ablation require further investigation.

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

Europace: 22 Aug 2020; epub ahead of print
Siontis KC, Kim HM, Vergara P, Peretto G, ... Morady F, Bogun FM
Europace: 22 Aug 2020; epub ahead of print | PMID: 32830247
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Abstract

Assessment of causality of natriuretic peptides and atrial fibrillation and heart failure: a Mendelian randomization study in the FINRISK cohort.

Geelhoed B, Börschel CS, Niiranen T, Palosaari T, ... Salomaa V, Schnabel RB
Aims
Natriuretic peptides are extensively studied biomarkers for atrial fibrillation (AF) and heart failure (HF). Their role in the pathogenesis of both diseases is not entirely understood and previous studies several single-nucleotide polymorphisms (SNPs) at the NPPA-NPPB locus associated with natriuretic peptides have been identified. We investigated the causal relationship between natriuretic peptides and AF as well as HF using a Mendelian randomization approach.
Methods and results
N-terminal pro B-type natriuretic peptide (NT-proBNP) (N = 6669), B-type natriuretic peptide (BNP) (N = 6674), and mid-regional pro atrial natriuretic peptide (MR-proANP) (N = 6813) were measured in the FINRISK 1997 cohort. N = 30 common SNPs related to NT-proBNP, BNP, and MR-proANP were selected from studies. We performed six Mendelian randomizations for all three natriuretic peptide biomarkers and for both outcomes, AF and HF, separately. Polygenic risk scores (PRSs) based on multiple SNPs were used as genetic instrumental variable in Mendelian randomizations. Polygenic risk scores were significantly associated with the three natriuretic peptides. Polygenic risk scores were not significantly associated with incident AF nor HF. Most cardiovascular risk factors showed significant confounding percentages, but no association with PRS. A causal relation except for small causal betas is unlikely.
Conclusion
In our Mendelian randomization approach, we confirmed an association between common genetic variation at the NPPA-NPPB locus and natriuretic peptides. A strong causal relationship between natriuretic peptides and incidence of AF as well as HF at the community-level was ruled out. Therapeutic approaches targeting natriuretic peptides will therefore very likely work through indirect mechanisms.

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

Europace: 22 Aug 2020; epub ahead of print
Geelhoed B, Börschel CS, Niiranen T, Palosaari T, ... Salomaa V, Schnabel RB
Europace: 22 Aug 2020; epub ahead of print | PMID: 32830215
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Impact:
Abstract

Left-sided accessory pathways successfully ablated from the aortomitral continuity region: distinctive atrial activation patterns and anatomic concerns.

Li MM, Long DY, Sang CH, Jiang CX, ... Du X, Ma CS
Aims
Accessory pathways (APs) successfully ablated at the aortomitral continuity (AMC) were sporadically reported but relevant data are very limited. We aimed to describe the electrophysiological characteristics of AMC-AP and the related anatomy.
Methods and results
This study involved eight (male/female = 3/5, mean age 42.6 ± 10.5 years) patients with left-sided AP successfully ablated in the AMC region. The retrograde atrial activation sequence was analysed and compared via recordings at the His-bundle (HB), coronary sinus (CS), and roving catheter during tachycardia, and the peak of QRS from the same cardiac circle used as time reference. Of the eight patients, two received prior ablations. During tachycardia, the activation time at the proximal CS (CSp), lateral CS (CSl), and HB region averaged 120 ± 26 ms, 124 ± 29 ms, and 117 ± 21 ms following the reference, respectively (P = 0.86). The latest atrial activation was recorded in the posterior CS which averaged 135 ± 25 ms following the reference. Placing the ablation catheter to AMC via retrograde approach was attempted in all cases but stable positioning achieved in none. Via transseptal approach, the ablation catheter could be easily placed at the AMC and recorded the earliest retrograde atrial activations with 60 ± 27 ms earlier than the relatively \'earliest\' CS/HB recordings, and ablation at this site successfully eliminated AP conduction. No patients had recovered AP conduction after at least 12-month follow-up.
Conclusion
AMC-AP is featured by recording comparable retrograde atrial activation times at CSp, CSl, and HB with the latest recordings at the posterior CS. Stable placement and successful ablation in the AMC via retrograde aortic approach was difficult but can be achieved via transseptal approach.

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

Europace: 22 Aug 2020; epub ahead of print
Li MM, Long DY, Sang CH, Jiang CX, ... Du X, Ma CS
Europace: 22 Aug 2020; epub ahead of print | PMID: 32830238
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Impact:
Abstract

The implications of catheter ablation for solitary atrial flutter in preventing stroke risk: a nationwide population-based cohort study.

Lin YS, Wu VC, Wang HT, Chen HC, ... Chu PH, Chen YL
Aims
The implications of ablation for atrial fibrillation in preventing stroke are controversial, and no studies have investigated whether ablation prevents ischaemic stroke (IS) in atrial flutter (AFL).
Methods and results
This study analysed data contained in the Taiwan National Health Insurance Research Database for 16 765 patients with a first diagnosis of solitary AFL during 2001-2013. Eligible patients were divided into two groups according to whether or not they had received ablation. Propensity score matching (PSM) was performed to mitigate the effects of potential confounding factors. The primary outcome was occurrence of IS during follow-up. After 1:2 PSM, the analysis included 1037 patients in the ablation group and 2074 patients in the non-ablation group. The incidence of IS was lower in the ablation group compared to the non-ablation group [subdistribution hazard ratio (SHR) 0.61, 95% confidence interval (CI) 0.41-0.90] during the 2-year follow-up period but not thereafter (SHR 1.03, 95% CI 0.72-1.48). When grouping by stroke history, it revealed that ablation affected the incidence of stroke in patients without history of stroke (SHR 0.59, 95% CI 0.38-0.91) but not in patients with history of stroke. When each group was stratified by CHA2DS2-VASc score, ablation lowered the incidence of stroke in patients with CHA2DS2-VASc ≤3 (SHR 0.31, 95% CI 0.16-0.60) but not in patients with CHA2DS2-VASc ≥4 in the initial 2-year follow-up.
Conclusion
The different incidence of IS in patients with/without ablation indicates that ablation reduces the risk of IS in AFL patients.

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

Europace: 22 Aug 2020; epub ahead of print
Lin YS, Wu VC, Wang HT, Chen HC, ... Chu PH, Chen YL
Europace: 22 Aug 2020; epub ahead of print | PMID: 32830229
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Impact:
Abstract

LA fibrosis predicts LVEF response after AF ablation in HF patients: the Fibrosis-HF Study.

Kirstein B, Neudeck S, Gaspar T, Piorkowski J, ... Huo Y, Piorkowski C
Aims
Atrial fibrillation (AF) and heart failure (HF) often coexist. Catheter ablation has been reported to restore left ventricular (LV) function but patients benefit differently. This study investigated the correlation between left atrial (LA) fibrosis extent and LV ejection fraction (LVEF) recovery after AF ablation.
Methods and results
In this study, 103 patients [64 years, 69% men, 79% persistent AF, LVEF 33% interquartile range (IQR) (25-38)] undergoing first time AF ablation were investigated. Identification of LA fibrosis and selection of ablation strategy were based on sinus rhythm voltage mapping. Continuous rhythm monitoring was used to assess ablation success. Improvement in post-ablation LVEF was measured as primary study endpoint. An absolute increase in post-ablation LVEF ≥10% was defined as \'Super Response\'. Left atrial fibrosis was present in 38% of patients. After ablation LVEF increased by absolute 15% (IQR 6-25) (P < 0.001). Left ventricular ejection fraction improvement was higher in patients without LA fibrosis [15% (IQR 10-25) vs. 10% (IQR 0-20), P < 0.001]. An inverse correlation between LVEF improvement and the extent of LA fibrosis was found (R2 = 0.931). In multivariate analysis, the presence of LA fibrosis was the only independent predictor for failing LVEF improvement [odds ratio 7.2 (95% confidence interval 2.2-23.4), P < 0.001]. Echocardiographic \'Super Response\' was observed in 55/64 (86%) patients without and 21/39 (54%) patients with LA fibrosis, respectively (P < 0.001).
Conclusion
Presence and extent of LA fibrosis predict LVEF response in HF patients undergoing AF ablation. The assessment of LA fibrosis may impact prognostic stratification and clinical management in HF patients with AF.

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

Europace: 22 Aug 2020; epub ahead of print
Kirstein B, Neudeck S, Gaspar T, Piorkowski J, ... Huo Y, Piorkowski C
Europace: 22 Aug 2020; epub ahead of print | PMID: 32830233
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Impact:
Abstract

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

Arbelo E, Aktaa S, Bollmann A, D\'Avila A, ... Dagres N,
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: 28 Aug 2020; epub ahead of print
Arbelo E, Aktaa S, Bollmann A, D'Avila A, ... Dagres N,
Europace: 28 Aug 2020; epub ahead of print | PMID: 32860039
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Impact:
Abstract

Efficacy and safety of ablation index-guided catheter ablation for atrial fibrillation: an updated meta-analysis.

Ioannou A, Papageorgiou N, Lim WY, Wongwarawipat T, ... Ahsan S, Providencia R
Aims 
Despite recent advances in catheter ablation for atrial fibrillation (AF), pulmonary vein reconnection (PVR), and AF recurrence remain significantly high. Ablation index (AI) is a new method incorporating contact force, time, and power that should optimize procedural outcomes. We aimed to evaluate the efficacy and safety of AI-guided catheter ablation compared to a non-AI-guided approach.
Methods and results 
A systematic search was performed on MEDLINE (via PubMED), EMBASE, COCHRANE, and European Society of Cardiology (ESC) databases (from inception to 1 July 2019). We included only studies that compared AI-guided with non-AI-guided catheter ablation of AF. Eleven studies reporting on 2306 patients were identified. Median follow-up period was 12 months. Ablation index-guided ablation had a significant shorter procedural time (141.0 vs. 152.8 min, P = 0.01; I2 = 90%), ablation time (21.8 vs. 32.0 min, P < 0.00001; I2 = 0%), achieved first-pass isolation more frequently [odds ratio (OR) = 0.09, 95%CI 0.04-0.21; 93.4% vs. 62.9%, P < 0.001; I2 = 58%] and was less frequently associated with acute PVR (OR = 0.37, 95%CI 0.18-0.75; 18.0% vs 35.0%; P = 0.006; I2 = 0%). Importantly, atrial arrhythmia relapse post-blanking was significantly lower in AI compared to non-AI catheter ablation (OR = 0.41, 95%CI 0.25-0.66; 11.8% vs. 24.9%, P = 0.0003; I2 = 35%). Finally, there was no difference in complication rate between AI and non-AI ablation, with the number of cardiac tamponade events in the AI group less being numerically lower (OR = 0.69, 95%CI 0.30-1.60, 1.6% vs. 2.5%, P = 0.39; I2 = 0%).
Conclusions 
These data suggest that AI-guided catheter ablation is associated with increased efficacy of AF ablation, while preserving a comparable safety profile to non-AI catheter ablation.

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

Europace: 29 Aug 2020; epub ahead of print
Ioannou A, Papageorgiou N, Lim WY, Wongwarawipat T, ... Ahsan S, Providencia R
Europace: 29 Aug 2020; epub ahead of print | PMID: 32862230
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Impact:
Abstract

High-density mapping in patients undergoing ablation of atrial fibrillation with the fourth-generation cryoballoon and the new spiral mapping catheter.

Conte G, Soejima K, de Asmundis C, Bruno J, ... Brugada P, Auricchio A
Aims
To assess the value of high-density mapping (HDM) in revealing undetected incomplete pulmonary vein isolation (PVI) after the fourth-generation cryoballoon (CB4G) ablation compared to the previous cryoballoon\'s versions.
Methods and results
Consecutive patients with paroxysmal or early-persistent atrial fibrillation (AF) undergoing CB ablation as the index procedure, assisted by HDM, were retrospectively included in this study. A total of 68 patients (52 males; mean age: 60 ± 12 years, 58 paroxysmal AF) were included, and a total of 272 veins were mapped. Fourth-generation cryoballoon with the new spiral mapping catheter (SMC) was used in 35 patients (51%). Time to PVI was determined in 102/132 (77%) and in 112/140 (80%) veins during second-generation cryoballoon/third-generation cryoballoon (CB2G/CB3G) and CB4G ablation, respectively (P = 0.66). There was a statistically significant difference in terms of discrepancy rate between the SMC and the mini-basket catheter in PV detection after CB4G and CB2G/CB3G ablation(1.4% vs. 7.6%; P = 0.01). A total of 57 patients (84%) remained free of symptomatic AF during a mean follow-up of 9.8 ± 4.6 months.
Conclusion
High-density mapping after cryoballoon ablation using CB4G and the new SMC identifies incomplete PVI, not detected by the new SMC, in a significantly lower proportion of veins compared to HDM performed after the other generation CB ablation.

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Europace: 22 Aug 2020; epub ahead of print
Conte G, Soejima K, de Asmundis C, Bruno J, ... Brugada P, Auricchio A
Europace: 22 Aug 2020; epub ahead of print | PMID: 32830231
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Impact:
Abstract

Machine learning does not improve upon traditional regression in predicting outcomes in atrial fibrillation: an analysis of the ORBIT-AF and GARFIELD-AF registries.

Loring Z, Mehrotra S, Piccini JP, Camm J, ... Pieper K, Kakkar AK
Aims
Prediction models for outcomes in atrial fibrillation (AF) are used to guide treatment. While regression models have been the analytic standard for prediction modelling, machine learning (ML) has been promoted as a potentially superior methodology. We compared the performance of ML and regression models in predicting outcomes in AF patients.
Methods and results
The Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) and Global Anticoagulant Registry in the FIELD (GARFIELD-AF) are population-based registries that include 74 792 AF patients. Models were generated from potential predictors using stepwise logistic regression (STEP), random forests (RF), gradient boosting (GB), and two neural networks (NNs). Discriminatory power was highest for death [STEP area under the curve (AUC) = 0.80 in ORBIT-AF, 0.75 in GARFIELD-AF] and lowest for stroke in all models (STEP AUC = 0.67 in ORBIT-AF, 0.66 in GARFIELD-AF). The discriminatory power of the ML models was similar or lower than the STEP models for most outcomes. The GB model had a higher AUC than STEP for death in GARFIELD-AF (0.76 vs. 0.75), but only nominally, and both performed similarly in ORBIT-AF. The multilayer NN had the lowest discriminatory power for all outcomes. The calibration of the STEP modelswere more aligned with the observed events for all outcomes. In the cross-registry models, the discriminatory power of the ML models was similar or lower than the STEP for most cases.
Conclusion
When developed from two large, community-based AF registries, ML techniques did not improve prediction modelling of death, major bleeding, or stroke.

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

Europace: 02 Sep 2020; epub ahead of print
Loring Z, Mehrotra S, Piccini JP, Camm J, ... Pieper K, Kakkar AK
Europace: 02 Sep 2020; epub ahead of print | PMID: 32879969
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Impact:
Abstract

Impact of the ablation technique on release of the neuronal injury marker S100B during pulmonary vein isolation.

Scherschel K, Hedenus K, Jungen C, Münkler P, ... Eickholt C, Meyer C
Aims
S100B, a well-known damage-associated molecular pattern protein is released acutely by central and peripheral nerves and upon concomitant denervation in pulmonary vein isolation (PVI). We aimed to investigate whether the ablation technique used for PVI impacts S100B release in patients with paroxysmal atrial fibrillation (AF).
Methods and results
The study population consisted of 73 consecutive patients (age: 62.7 ± 10.9 years, 54.8% males) undergoing first-time PVI with either radiofrequency (RF; n = 30) or cryoballoon (CB; n = 43) for paroxysmal AF. S100B determined from venous plasma samples taken immediately before and after PVI increased from 33.5 ± 1.8 to 91.1 ± 5.3 pg/mL (P < 0.0001). S100B release in patients undergoing CB-PVI was 3.9 times higher compared to patients with RF-PVI (ΔS100B: 21.1 ± 2.7 vs. 83.1 ± 5.2  pg/mL, P < 0.0001). During a mean follow-up of 314 ± 186 days, AF recurrences were observed in 18/71 (25.4%) patients (RF-PVI: n = 9/28, CB-PVI: n = 9/43). Univariate Cox regression analysis indicated that an increase in S100B was associated with higher freedom from AF in follow-up (hazard ratio per 10  pg/mL release of S100B: 0.83; 95% confidence interval: 0.72-0.95; P = 0.007).
Conclusion
The ablation technique used for PVI has an impact on the release of S100B, a well-established biomarker for neural damage.

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

Europace: 22 Aug 2020; epub ahead of print
Scherschel K, Hedenus K, Jungen C, Münkler P, ... Eickholt C, Meyer C
Europace: 22 Aug 2020; epub ahead of print | PMID: 32830253
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Impact:
Abstract

Atrial fibrillation detection by the subcutaneous defibrillator: real-world clinical performances and implications from a multicentre study.

Ollitrault P, Jacon P, Auquier N, Champ-Rigot L, ... Anselme F, Milliez P
Aims
No data exist concerning the clinical performances of the subcutaneous implantable cardioverter-defibrillator (S-ICD) atrial fibrillation (AF) detection algorithm. We aimed to study the performances and implications of the latter in a \'real-world\' setting.
Methods and results
Between July 2017 and August 2019, 155 consecutive S-ICD recipients were included. Endpoint of the study was the incidence of de novo or recurrent AF using a combined on-site and remote-monitoring follow-up approach. After a mean follow-up of 13 ± 8 months, 2531 AF alerts were generated for 55 patients. A blinded analysis of the 1950 subcutaneous electrocardiograms available was performed. Among them 47% were true AF, 23% were premature atrial contractions or non-sustained AF, 29% were premature ventricular contractions or non-sustained ventricular tachycardia, and 1% were misdetection. Fourteen percent (21/155) patients had at least one correct diagnosis of AF by the S-ICD algorithm. One patient presented symptomatic paroxysmal AF not diagnosed by the S-ICD algorithm (false negative patient). Patient-based sensitivity, specificity, positive, and negative predictive values were respectively 95%, 74%, 38%, and 99%. Among patients with at least one correct diagnosis of AF, 38% (8/21) had subsequent clinical implications (anticoagulation initiation or rhythm control therapies).
Conclusion
The S-ICD AF detection algorithm yields a high sensitivity for AF diagnosis. Low specificity and positive predictive value contribute to a high remote monitoring-notification workload and underline the necessity of a manual analysis. Atrial fibrillation diagnosis by the S-ICD AF detection algorithm might lead to significant therapeutic adjustments.

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

Europace: 22 Aug 2020; epub ahead of print
Ollitrault P, Jacon P, Auquier N, Champ-Rigot L, ... Anselme F, Milliez P
Europace: 22 Aug 2020; epub ahead of print | PMID: 32830226
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Impact:
Abstract

Biventricular implantable cardioverter-defibrillator device placement in patients with hostile tricuspid valve anatomy: two case reports and review of the literature.

Maskoun W, Raad M, Khan A, Mando R, Homsi M
Aims
Right ventricular (RV) lead placement can be contraindicated in patients after tricuspid valve (TV) surgery. Placement of the implantable cardiac-defibrillator (ICD) lead in the middle cardiac vein (MCV) can be a viable option in these patients who have an indication for biventricular (BiV) ICD. We aim to describe the case of two patients with MCV lead placement and provide a comprehensive review of patients with complex TV pathology and indications for RV lead placement.
Methods and results
We describe the cases of two patients with TV pathology unsuitable for the standard transvenous or surgical RV lead placement and undergoing BiV ICD implantation. Their characteristics, procedure, and outcomes are summarized. The BiV ICD was successfully placed with the RV lead positioned in the MCV in both patients. The procedures had no complications and were well-tolerated. On follow-up, both patients had appropriate tachytherapy with no readmissions for heart failure or worsening of cardiac function.
Conclusion
Right ventricular lead placement of BiV ICD in the MCV can be an excellent alternative in patients with significant TV pathology and poor surgical candidacy.

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

Europace: 22 Aug 2020; epub ahead of print
Maskoun W, Raad M, Khan A, Mando R, Homsi M
Europace: 22 Aug 2020; epub ahead of print | PMID: 32830224
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Impact:
Abstract

QRS complex axis deviation changing in catheter ablation of left fascicular ventricular tachycardia.

Zhou G, Lu X, Nie Z, Chen S, ... Wang Z, Liu S
Aims
The mechanisms of the QRS complex axis deviation changing of idiopathic left fascicular ventricular tachycardia (FVT) during or after radiofrequency catheter ablation were investigated in this study, which were still not well defined.
Methods and results
In the index procedure, FVTs characterized by right bundle branch block configuration and left-axis deviation (LAD-FVT) were ablated at the VT exit site guided by the earliest ventricular activation with fused presystolic Purkinje potential (PP) in 234 consecutive patients. A new type of FVT characterized by right-axis deviation (RAD-FVT) was identified after successful elimination of the LAD-FVT in 12 patients, including 9 patients during the index procedure and 3 patients during follow-up. The QRS duration of RAD-FVT was shorter than that of LAD-FVT (115.3 ± 15.2 vs. 125.3 ± 16.4 ms, P = 0.006). The RAD-FVTs showed an earliest ventricle activation site localized at anterior fascicle area in 11 patients and anterior-median fascicle area in 1. However, the earliest PP during the RAD-FVT was still identified within the posterior fascicular network. Elimination of the RAD-FVTs was successfully achieved by applying radiofrequency current at a more proximal site within the left posterior fascicular network guided by the earliest PP. After a mean of 1.6 ± 0.8 ablation procedures and median follow-up of 132 (range 19-216) months since the last procedure, no recurrence was observed in any patients.
Conclusion
The axis deviation changing of QRS complex in FVT may be attributed to the different exit sites of the reentry.

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

Europace: 04 Sep 2020; epub ahead of print
Zhou G, Lu X, Nie Z, Chen S, ... Wang Z, Liu S
Europace: 04 Sep 2020; epub ahead of print | PMID: 32888292
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Abstract

Implementation of an on-demand app-based heart rate and rhythm monitoring infrastructure for the management of atrial fibrillation through teleconsultation: TeleCheck-AF.

Pluymaekers NAHA, Hermans ANL, van der Velden RMJ, Gawałko M, ... Hendriks JM, Linz D

During the coronavirus 2019 (COVID-19) pandemic, outpatient visits in the atrial fibrillation (AF) clinic of the Maastricht University Medical Centre (MUMC+) were transferred into teleconsultations. The aim was to develop anon-demand app-based heart rate and rhythm monitoring infrastructure to allow appropriatmanagement of AF through teleconsultation. In line with the fundamental aspects of integrated care, including actively involving patients in the care process and providing comprehensive care by a multidisciplinary team, we implemented a mobile health (mHealth) intervention to support teleconsultations with AF patients: TeleCheck-AF. The TeleCheck-AF approach guarantees the continuity of comprehensive AF management and supports integrated care through teleconsultation during COVID-19. It incorporates three important components: (i) a structured teleconsultation (\'Tele\'), (ii) a CE-marked app-based on-demand heart rate and rhythm monitoring infrastructure (\'Check\'), and (iii) comprehensive AF management (\'AF\'). In this article, we describe the components and implementation of the TeleCheck-AF approach in an integrated and specialized AF-clinic through teleconsultation. The TeleCheck-AF approach is currently implemented in numerous European centres during COVID-19.

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

Europace: 03 Sep 2020; epub ahead of print
Pluymaekers NAHA, Hermans ANL, van der Velden RMJ, Gawałko M, ... Hendriks JM, Linz D
Europace: 03 Sep 2020; epub ahead of print | PMID: 32887994
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Impact:
Abstract

Standardized pulmonary vein isolation workflow to enclose veins with contiguous lesions: the multicentre VISTAX trial.

Duytschaever M, Vijgen J, De Potter T, Scherr D, ... Macours N, Gupta D
Aims
To evaluate the safety and effectiveness of pulmonary vein isolation in paroxysmal atrial fibrillation (PAF) using a standardized workflow aiming to enclose the veins with contiguous and optimized radiofrequency lesions.
Methods and results
This multicentre, prospective, non-randomized study was conducted at 17 European sites. Pulmonary vein isolation was guided by VISITAG SURPOINT (VS target ≥550 on the anterior wall; ≥400 on the posterior wall) and intertag distance (≤6 mm). Atrial arrhythmia recurrence was stringently monitored with weekly and symptom-driven transtelephonic monitoring on top of standard-of-care monitoring (24-h Holter and 12-lead electrocardiogram at 3, 6, and 12 months follow-up). Three hundred and forty participants with drug refractory PAF were enrolled. Acute effectiveness (first-pass isolation proof to a 30-min wait period and adenosine challenge) was 82.4% [95% confidence interval (CI) 77.4-86.7%]. At 12-month follow-up, the rate of freedom from any documented atrial arrhythmia was 78.3% (95% CI 73.8-82.8%), while freedom from atrial arrhythmia by standard-of-care monitoring was 89.4% (95% CI 78.8-87.0%). Freedom fromrepeat ablations by the Kaplan-Meier analysis was 90.4% during 12 months of follow-up. Of the 34 patients with repeat ablations, 14 (41.2%) demonstrated full isolation of all pulmonary vein circles. Primary adverse event (PAE) rate was 3.6% (95% CI 1.9-6.3%).
Conclusions
The VISTAX trial demonstrated that a standardized PAF ablation workflow aiming for contiguous lesions leads to low rates of PAEs, high acute first-pass isolation rates, and 12-month freedom from arrhythmias approaching 80%. Further research is needed to improve the reproducibility of the outcomes across a wider range of centres.Clinical trial registration: ClinicalTrials.gov, number NCT03062046, https://clinicaltrials.gov/ct2/show/NCT03062046.

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

Europace: 02 Sep 2020; epub ahead of print
Duytschaever M, Vijgen J, De Potter T, Scherr D, ... Macours N, Gupta D
Europace: 02 Sep 2020; epub ahead of print | PMID: 32879974
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Impact:
Abstract

Timing and evolution of advanced conduction disturbances in patients with right bundle branch block undergoing transcatheter aortic valve replacement.

Muntané-Carol G, Del Val D, Junquera L, Faroux L, ... Philippon F, Rodés-Cabau J
Aims
This study sought to determine the timing and evolution over time of advanced conduction disturbances (CDs) in patients with baseline right bundle branch block (RBBB) undergoing transcatheter aortic valve replacement (TAVR).
Methods and results
One hundred and ten consecutive patients with pre-existing RBBB were included (out of 1341, 8.2%). All arrhythmias during the hospitalization period were recorded. Follow-up was performed at 30 days, 1 year, and yearly thereafter. Conduction recovery and ventricular pacing percentage (VPP) was evaluated at 30 days in those patients with permanent pacemaker implantation (PPMI). Sixty-one (55.5%) patients suffered advanced CDs [97% complete or high-degree atrioventricular block (CHB/HAVB)], and the vast majority (98%) occurred within the first 3 days post-procedure (intraprocedural: 85%). Fifty-two (47.3%) patients had PPMI (vs. 11.0% in non-RBBB patients, P < 0.001). Ventricular pacing percentage at 1 month was higher in patients with persistent-intraprocedural CHB/HAVB compared to those with transient-intraprocedural or post-procedural CHB/HAVB [99 (interquartile range, IQR 97-100)% vs. 72 (IQR 30-99)%, P = 0.02]. Complete recovery (VPP < 1%) was observed in only one patient (2%) with CHB/HAVB. After hospital discharge, no symptomatic bradyarrhythmias or sudden death occurred within 30 days. Patients with pre-existing RBBB exhibited a higher risk of PPMI at 4-year follow-up (26% vs. 8% in non-RBBB patients, P < 0.001).
Conclusion
In patients with pre-existing RBBB, the vast majority of advanced CDs occurred within the 3 days following TAVR, and most did not recover at 1-month, particularly those with intra-procedural persistent CHB/HAVB. These results should help to determine the hospitalization length and timing of PPMI in RBBB patients undergoing TAVR.

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

Europace: 31 Aug 2020; epub ahead of print
Muntané-Carol G, Del Val D, Junquera L, Faroux L, ... Philippon F, Rodés-Cabau J
Europace: 31 Aug 2020; epub ahead of print | PMID: 32869083
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Impact:
Abstract

Competing risk analysis of ventricular arrhythmia events in heart failure patients with moderately compromised renal dysfunction.

Goldenberg I, Younis A, Aktas MK, McNitt S, Zareba W, Kutyifa V
Aims
Patients with impaired renal function were shown to have an attenuated benefit from implantable cardioverter-defibrillator. However, there are limited data on the competing risk of ventricular arrhythmia events and death by renal function in patients without severe disease. Therefore, we aimed to assess the competing risk of ventricular arrhythmia events and death by renal function.
Methods and results
We analysed 1782 patients (99%) enrolled in Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT) with glomerular filtration rate (GFR) data available. Cumulative incidence function curves were used to display the rate of ventricular tachycardia (VT), ventricular fibrillation (VF), and the competing risk of death without experiencing VT/VF. Multivariable Fine and Gray regression models and recurrent event analysis were performed. There were 355 (20%) patients with GFR < 52 and 1427 with GFR ≥ 52 (lowest quintile). The incidence of non-fatal VT/VF at 4 years was higher in patients with high GFR (26%) as compared to low GFR (16%), whereas rates of death without non-fatal VT/VF were 5% and 20% (P < 0.001). In Fine and Gray models, the low GFR group was 35% less likely to experience VT/VF compared to the high GFR [95% confidence interval (CI) 0.48-0.88, P = 0.005]. In contrast,death without experiencing VT/VF was 3.5-fold higher in the low GFR group (95% CI 2.38-5.12, P-value < 0.001). Recurrent event analysis consistently showed a lower risk of recurrent VT/VF, recurrent anti-tachycardia pacing only, and shock in the low GFR group.
Conclusions
We show, in a competing risk model, a lower risk of VT/VF events and a higher risk of mortality without an arrhythmic event in patients with moderate renal dysfunction in MADIT-CRT. These findings can be used for improved selection of patients for defibrillator therapy among CRT candidates.
Clinical trial registration
https://clinicaltrials.gov/ct2/show/NCT00180271.

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

Europace: 31 Aug 2020; epub ahead of print
Goldenberg I, Younis A, Aktas MK, McNitt S, Zareba W, Kutyifa V
Europace: 31 Aug 2020; epub ahead of print | PMID: 32875313
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Impact:
Abstract

Ventricular arrhythmia risk is associated with myocardial scar but not with response to cardiac resynchronization therapy.

Linhart M, Doltra A, Acosta J, Borràs R, ... Mont L, Berruezo A
Aims
Sudden cardiac death (SCD) risk estimation in patients referred for cardiac resynchronization therapy (CRT) remains a challenge. By CRT-mediated improvement of left ventricular ejection fraction (LVEF), many patients loose indication for primary prevention implantable cardioverter-defibrillator (ICD). Increasing evidence shows the importance of myocardial scar for risk prediction. The aim of this study was to investigate the prognostic impact of myocardial scar depending on the echocardiographic response in patients undergoing CRT.
Methods and results
Patients with indication for CRT were prospectively enrolled. Decision about ICD or pacemaker implantation was based on clinical criteria. All patients underwent delayed-enhancement cardiac magnetic resonance imaging. Median follow-up duration was 45 (24-75) months. Primary outcome was a composite of sustained ventricular arrhythmia, appropriate ICD therapy, or SCD. A total of 218 patients with LVEF 25.5 ± 6.6% were analysed [158 (73%) male, 64.9 ± 10.7 years]. Myocardial scar was observed in 73 patients with ischaemic cardiomyopathy (ICM) (95% of ICM patients); in 62 with non-ischaemic cardiomyopathy (45% of these patients); and in all but 1 of 36 (17%) patients who reached the primary outcome. Myocardial scar was the only significant predictor of primary outcome [odds ratio 27.7 (3.8-202.7)], independent of echocardiographic CRT response. A total of 55 (25%) patients died from any cause or received heart transplant. For overall survival, only a combination of the absence of myocardial scar with CRT response was associated with favourable outcome.
Conclusion
Malignant arrhythmic events and SCD depend on the presence of myocardial scar but not on CRT response. All-cause mortality improved only with the combined absence of myocardial scar and CRT response.

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Europace: 31 Aug 2020; 22:1391-1400
Linhart M, Doltra A, Acosta J, Borràs R, ... Mont L, Berruezo A
Europace: 31 Aug 2020; 22:1391-1400 | PMID: 32898254
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Abstract

The harm of delayed diagnosis of arrhythmogenic cardiac sarcoidosis: a case series.

Hoogendoorn JC, Ninaber MK, Piers SRD, de Riva M, ... Bogun FM, Zeppenfeld K
Aims
Cardiac sarcoidosis (CS) is a known cause of ventricular tachycardia (VT). However, an arrhythmogenic presentation may not prompt immediate comprehensive evaluation. We aimed to assess the diagnostic and disease course of patients with arrhythmogenic cardiac sarcoidosis (ACS).
Methods and results
From the Leiden VT-ablation-registry, consecutive patients with CS as underlying aetiology were retrospectively included. Data on clinical presentation, time-to-diagnosis, cardiac function, and clinical outcomes were collected. Patients were divided in early (<6 months from first cardiac presentation) and late diagnosis. After exclusion of patients with known causes of non-ischaemic cardiomyopathy (NICM), 15 (12%) out of 129 patients with idiopathic NICM were ultimately diagnosed with CS and included. Five patients were diagnosed early; all had early presentation with VTs. Ten patients had a late diagnosis with a median delay of 24 (IQR 15-44) months, despite presentation with VT (n = 5) and atrioventricular block (n = 4). In 6 of 10 patients, reason for suspicion of ACS was the electroanatomical scar pattern. In patients with early diagnosis, immunosuppressive therapy was immediately initiated with stable cardiac function during follow-up. Adversely, in 7 of 10 patients with late diagnosis, cardiac function deteriorated before diagnosis, and in only one cardiac function recovered with immunosuppressive therapy. Six (40%) patients died (five of six with late diagnosis).
Conclusion
Arrhythmogenic cardiac sarcoidosis is an important differential diagnosis in NICM patients referred for VT ablation. Importantly, the diagnosis is frequently delayed, which leads to a severe disease course, including irreversible cardiac dysfunction and death. Early recognition, which can be facilitated by electroanatomical mapping, is crucial.

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

Europace: 31 Aug 2020; 22:1376-1383
Hoogendoorn JC, Ninaber MK, Piers SRD, de Riva M, ... Bogun FM, Zeppenfeld K
Europace: 31 Aug 2020; 22:1376-1383 | PMID: 32898252
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Abstract

Usefulness of post-procedural heart rate response to predict syncope recurrence or positive head up tilt table testing after cardioneuroablation.

Aksu T, Guler TE, Bozyel S, Yalin K, Gopinathannair R
Aims
Previous reports have suggested that cardioneuroablation (CNA) can be effective in reducing syncopal recurrences in patients with vasovagal syncope (VVS). This study assessed the efficacy of CNA in preventing a positive response to head-up tilt testing (HUT).
Methods and results
This is a single-centre retrospective study reviewing prospectively collected data. Fifty-one consecutive patients with VVS were included in the study. After confirmation of >3 s asystole on HUT, all patients underwent CNA. Head-up tilt testing was repeated 1 month after CNA. The main outcome measures were recurrence of syncope episode and positive response on HUT. During a median follow-up period of 11 months (interquartile range 3-27 months), all but 3 (5.8%) of 51 patients were free of syncope. Repeated HUTs were negative in 44 (86.2%) patients. When patients with recurrent syncope were excluded, vasodepressor response was seen in three cases and cardioinhibitory response in one case, respectively. Cardioneuroablation caused significant and durable shortening of RR interval in all cases. This effect was significantly higher in patients without positive HUT responses.
Conclusion
This pilot study shows that CNA can effectively prevent recurrent syncopal episodes in patients with refractory VVS. Head-up tilt testing seems as a valuable diagnostic tool not only to select suitable candidates and but also to evaluate success of CNA.

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

Europace: 31 Aug 2020; 22:1320-1327
Aksu T, Guler TE, Bozyel S, Yalin K, Gopinathannair R
Europace: 31 Aug 2020; 22:1320-1327 | PMID: 32898255
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Impact:
Abstract

Myocardial infarction or acute coronary syndrome with non-obstructive coronary arteries and sudden cardiac death: a missing connection.

Kosmas N, Manolis AS, Dagres N, Iliodromitis EK

Myocardial infarction with non-obstructive coronary arteries or any acute coronary syndrome (ACS) with normal or near-normal (non-obstructive) coronary arteries (ACS-NNOCA) is an heterogeneous clinical entity, which includes different pathophysiology mechanisms and is challenging to treat. Sudden cardiac death (SCD) is a catastrophic manifestation of ACS that is crucial to prevent and treat urgently. The concurrence of the two conditions has not been adequately studied. This narrative review focuses on the existing literature concerning ACS-NNOCA pathophysiology, with an emphasis on SCD, together with risk and outcome data from clinical trials. There have been no large-scale studies to investigate the incidence of SCD within ACS-NNOCA patients, both early and late in the disease. Some pathophysiology mechanisms that are known to mediate ACS-NNOCA, such as atheromatous plaque erosion, anomalous coronary arteries, and spontaneous coronary artery dissection are documented causes of SCD. Myocardial ischaemia, inflammation, and fibrosis are probably at the core of the SCD risk in these patients. Effective treatments to reduce the relevant risk are still under research. ACS-NNOCA is generally considered as an ACS with more \'benign\' outcome compared to ACS with obstructive coronary artery disease, but its relationship with SCD remains obscure, especially until its incidence and effective treatment are evaluated.

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

Europace: 31 Aug 2020; 22:1303-1310
Kosmas N, Manolis AS, Dagres N, Iliodromitis EK
Europace: 31 Aug 2020; 22:1303-1310 | PMID: 32894280
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Impact:
Abstract

Long-term impact of the burden of new-onset atrial fibrillation in patients with acute myocardial infarction: results from the NOAFCAMI-SH registry.

Luo J, Xu S, Li H, Gong M, ... Shi B, Wei Y
Aims 
We aimed to investigate the prognostic impact of the burden of new-onset atrial fibrillation (NOAF) on long-term cardiovascular outcomes in patients with acute myocardial infarction (AMI).
Methods and results 
This retrospective analysis consecutively included patients without a documented atrial fibrillation (AF) history who admitted for AMI at Shanghai Tenth People\'s Hospital between February 2014 and March 2018. Atrial fibrillation burden was measured as the percentage of time spent in AF, and its optimal cut-off value of 10.87% was identified by X-tile software. Of 2399 patients (mean age: 65.8 years, 76.6% of men), 278 (11.6%) developed NOAF during hospitalization. During a median follow-up of 2.7 years, the incidence of all-cause death was 3.19, 9.00, and 17.41 per 100 person-years in the sinus rhythm (SR), low-burden (AF burden ≤ 10.87%), and high-burden (AF burden > 10.87%) groups, respectively. After adjustment for confounders, it was the high-burden NOAF [hazard ratio (HR): 1.94, 95% confidence interval (CI): 1.28-2.95] rather than the low-burden one (HR: 1.47, 95% CI: 0.97-2.21) that was significantly associated with increased mortality compared with SR. Concordant results were obtained in our propensity score-matched analyses [2.55 (1.57-4.16) and 1.32 (0.85-2.05) for high- and low-burden NOAF, respectively). In addition, post-myocardial infarction NOAF was associated with an increased risk of heart failure irrespective of its burden. Only those high-burden individuals were at heightened risk of ischaemic stroke. The restricted cubic spline curves illustrated a dose-response relationship of NOAF burden with outcomes.
Conclusion
In patients with NOAF complicating AMI, high AF burden was strongly associated with long-term outcomes.

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

Europace: 14 Sep 2020; epub ahead of print
Luo J, Xu S, Li H, Gong M, ... Shi B, Wei Y
Europace: 14 Sep 2020; epub ahead of print | PMID: 32929491
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Impact:
Abstract

Utilization and procedural adverse outcomes associated with Watchman device implantation.

Khalil F, Arora S, Killu AM, Tripathi B, ... Holmes D, Deshmukh AJ
Aims 
The Food and Drug Administration (FDA) approval of the Watchman device [percutaneous left atrial appendage occlusion (LAAO)] has resulted in the widespread use of this procedure in many centres across the USA. We sought to estimate the nationwide utilization and frequency of adverse outcomes associated with Watchman device implantation. The objective of this study was to evaluate the Watchman device implantation peri-procedural complications and comparison of the results with the previous studies.
Methods and results 
The National Inpatient Sample (NIS) was queried for all hospitalizations with a primary diagnosis of atrial fibrillation or atrial flutter during the year 2016 with percutaneous LAAO during the same admission (ICD-10 code-02L73DK). The frequency of peri-procedural complications, including mortality, procedure-related stroke, major bleeding requiring blood transfusion, and pericardial effusion, was assessed. We compared the complication rates with the published randomized controlled trials and the European Watchman registry. An estimated 5175 LAAO procedures were performed in 2016. The majority of procedures was performed in males (59.1%), age ≥75 years (58.7%), and White (83.1%). The overall complication rate was 1.9%. The in-hospital mortality was 0.29%. Pericardial effusion requiring pericardiocentesis was the most frequent complication (0.68%). Bleeding requiring transfusion was noted in 0.1% of device implants. The rates of post-procedure stroke and systemic embolism were 0% and 0.29%, respectively.
Conclusion 
Percutaneous LAAO with the Watchman device in the USA is associated with low in-hospital complications and a similar safety profile to a recently published EWOLUTION cohort. The complication rates were lower than those reported in the major randomized clinical trials (RCTs). We report the frequency of peri-procedural complications of the LAAO using the Watchman device from the NIS database. We also compare the frequency of peri-procedural complications with the previously published RCTs and EWOLUTION cohort. Our findings are in concordance with findings from EWOLUTION cohort and compare favourably with RCTs.

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Europace: 13 Sep 2020; epub ahead of print
Khalil F, Arora S, Killu AM, Tripathi B, ... Holmes D, Deshmukh AJ
Europace: 13 Sep 2020; epub ahead of print | PMID: 32929501
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Impact:
Abstract

Defining the normal QT interval in newborns: the natural history and reference values for the first 4 weeks of life.

Pærregaard MM, Hvidemose SO, Pihl C, Sillesen AS, ... Bundgaard H, Christensen AH
Aims
Evaluation of the neonatal QT interval is important to diagnose arrhythmia syndromes and evaluate side effects of drugs. We aimed at describing the natural history of the QT interval duration during the first 4 weeks of life and to provide reference values from a large general population sample.
Methods and results
The Copenhagen Baby Heart Study is a prospective general population study that offered cardiac evaluation of newborns. Eight-lead electrocardiograms were obtained and analysed with a computerized algorithm with manual validation. We included 14 164 newborns (52% boys), aged 0-28 days, with normal echocardiograms. The median values (ms, 2-98%ile) for the corrected intervals QTc (Bazett), QTc (Hodges), QTc (Fridericia), and QTc (Framingham) were 419 (373-474), 419 (373-472), 364 (320-414), and 363 (327-405). During the 4 weeks, we observed a small decrease of QTcFramingham, and an increase of QTcHodges (both P < 0.01), while QTcBazett and QTcFridericia did not change (P > 0.05). Applying published QT interval cut-off values resulted in 5-25% of the newborns having QT prolongation. Uncorrected QT intervals decreased linearly with increasing heart rate (HR). Sex and infant size did not affect the QT interval and the gestational age (GA) only showed an effect when comparing the extreme low- vs. high GA groups (≤34 vs. ≥42 weeks, P = 0.021).
Conclusion
During the 4 weeks QTcFramingham and QTcHodges showed minor changes, whereas QTcBazett and QTcFridericia were stable. The QT interval was unaffected by sex and infant size and GA only showed an effect in very premature newborns. Reference values for HR-specific uncorrected QT intervals may facilitate a more accurate diagnosis of newborns with abnormal QT intervals.

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

Europace: 16 Sep 2020; epub ahead of print
Pærregaard MM, Hvidemose SO, Pihl C, Sillesen AS, ... Bundgaard H, Christensen AH
Europace: 16 Sep 2020; epub ahead of print | PMID: 32940668
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Impact:
Abstract

Arrhythmic safety of hydroxychloroquine in COVID-19 patients from different clinical settings.

Gasperetti A, Biffi M, Duru F, Schiavone M, ... Tondo C, Forleo GB
Aims
The aim of the study was to describe ECG modifications and arrhythmic events in COVID-19 patients undergoing hydroxychloroquine (HCQ) therapy in different clinical settings.
Methods and results
COVID-19 patients at seven institutions receiving HCQ therapy from whom a baseline and at least one ECG at 48+ h were available were enrolled in the study. QT/QTc prolongation, QT-associated and QT-independent arrhythmic events, arrhythmic mortality, and overall mortality during HCQ therapy were assessed. A total of 649 COVID-19 patients (61.9 ± 18.7 years, 46.1% males) were enrolled. HCQ therapy was administrated as a home therapy regimen in 126 (19.4%) patients, and as an in-hospital-treatment to 495 (76.3%) hospitalized and 28 (4.3%) intensive care unit (ICU) patients. At 36-72 and at 96+ h after the first HCQ dose, 358 and 404 ECGs were obtained, respectively. A significant QT/QTc interval prolongation was observed (P < 0.001), but the magnitude of the increase was modest [+13 (9-16) ms]. Baseline QT/QTc length and presence of fever (P = 0.001) at admission represented the most important determinants of QT/QTc prolongation. No arrhythmic-related deaths were reported. The overall major ventricular arrhythmia rate was low (1.1%), with all events found not to be related to QT or HCQ therapy at a centralized event evaluation. No differences in QT/QTc prolongation and QT-related arrhythmias were observed across different clinical settings, with non-QT-related arrhythmias being more common in the intensive care setting.
Conclusion
HCQ administration is safe for a short-term treatment for patients with COVID-19 infection regardless of the clinical setting of delivery, causing only modest QTc prolongation and no directly attributable arrhythmic deaths.

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

Europace: 23 Sep 2020; epub ahead of print
Gasperetti A, Biffi M, Duru F, Schiavone M, ... Tondo C, Forleo GB
Europace: 23 Sep 2020; epub ahead of print | PMID: 32971536
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Impact:
Abstract

Frequency of injuries associated with syncope in the prevention of syncope trials.

Jorge JG, Pournazari P, Raj SR, Maxey C, Sheldon RS
Aims
Syncope can lead to injuries. We determined the frequency, severity, and predictors of injuries due to syncope in cohorts of syncope patients.
Methods and results
Participants were enrolled in the POST2 (fludrocortisone) and POST4 (midodrine) vasovagal syncope (VVS) randomized trials, and POST3 enrolled patients with bifascicular block and syncope. Injury was defined as minor (bruising, abrasions), moderate (lacerations), and severe (fractures, burns, joint pain), and recorded up to 1 year after enrolment. A total of 459 patients (median 39 years) were analysed. There were 710 faints occurred in 186 patients during a 1-year follow-up. Fully 56/186 (30%) of patients were injured with syncope (12% of overall group). There were 102 injuries associated with the 710 faints (14%), of which 19% were moderate or severe injuries. Neither patient age, sex, nor the presence of prodromal symptoms associated with injury-free survival. Patients with bifascicular block were more prone to injury (relative risk 1.98, P = 0.018). Patients with ≥4 faints in the prior year had more injuries than those with fewer faints (relative risk 2.97, P < 0.0001), but this was due to more frequent syncope, and not more injuries per faint. In VVS patients, pharmacological therapy significantly reduced the likelihood of an injury due to a syncopal spell (relative risk 0.64, P = 0.015). Injury severity did not associate with age, sex, or prior-year syncope frequency.
Conclusion
Injuries are frequent in syncope patients, but only 4% of injuries were severe. None of age, sex, and prodromal symptoms associate with injury.

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

Europace: 19 Sep 2020; epub ahead of print
Jorge JG, Pournazari P, Raj SR, Maxey C, Sheldon RS
Europace: 19 Sep 2020; epub ahead of print | PMID: 32954415
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Impact:
Abstract

Electrocardiographic features of 431 consecutive, critically ill COVID-19 patients: an insight into the mechanisms of cardiac involvement.

Bertini M, Ferrari R, Guardigli G, Malagù M, ... Aschieri D, Rapezzi C
Aims
Our aim was to describe the electrocardiographic features of critical COVID-19 patients.
Methods and results
We carried out a multicentric, cross-sectional, retrospective analysis of 431 consecutive COVID-19 patients hospitalized between 10 March and 14 April 2020 who died or were treated with invasive mechanical ventilation. This project is registered on ClinicalTrials.gov (identifier: NCT04367129). Standard ECG was recorded at hospital admission. ECG was abnormal in 93% of the patients. Atrial fibrillation/flutter was detected in 22% of the patients. ECG signs suggesting acute right ventricular pressure overload (RVPO) were detected in 30% of the patients. In particular, 43 (10%) patients had the S1Q3T3 pattern, 38 (9%) had incomplete right bundle branch block (RBBB), and 49 (11%) had complete RBBB. ECG signs of acute RVPO were not statistically different between patients with (n = 104) or without (n=327) invasive mechanical ventilation during ECG recording (36% vs. 28%, P = 0.10). Non-specific repolarization abnormalities and low QRS voltage in peripheral leads were present in 176 (41%) and 23 (5%), respectively. In four patients showing ST-segment elevation, acute myocardial infarction was confirmed with coronary angiography. No ST-T abnormalities suggestive of acute myocarditis were detected. In the subgroup of 110 patients where high-sensitivity troponin I was available, ECG features were not statistically different when stratified for above or below the 5 times upper reference limit value.
Conclusions
The ECG is abnormal in almost all critically ill COVID-19 patients and shows a large spectrum of abnormalities, with signs of acute RVPO in 30% of the patients. Rapid and simple identification of these cases with ECG at hospital admission can facilitate classification of the patients and provide pathophysiological insights.

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

Europace: 17 Sep 2020; epub ahead of print
Bertini M, Ferrari R, Guardigli G, Malagù M, ... Aschieri D, Rapezzi C
Europace: 17 Sep 2020; epub ahead of print | PMID: 32944767
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Impact:
Abstract

Management of ventricular electrical storm: a contemporary appraisal.

Kowlgi GN, Cha YM

Ventricular electrical storm (VES) is a clinical scenario characterized by the clustering of multiple episodes of sustained ventricular arrhythmias (VA) over a short duration. Patients with VES are prone to psychological disorders, heart failure decompensation, and increased mortality. Studies have shown that 10-28% of the patients with secondary prevention ICDs can sustain VES. The triad of a susceptible electrophysiologic substrate, triggers, and autonomic dysregulation govern the pathogenesis of VES. The rate of VA, underlying ventricular function, and the presence of implantable cardioverter-defibrillator (ICD) determine the clinical presentation. A multi-faceted approach is often required for management consisting of acute hemodynamic stabilization, ICD reprogramming when appropriate, antiarrhythmic drug therapy, and sedation. Some patients may be eligible for catheter ablation, and autonomic modulation with thoracic epidural anesthesia, stellate ganglion block, or cardiac sympathetic denervation. Hemodynamically unstable patients may benefit from the use of left ventricular assist devices, and extracorporeal membrane oxygenation. Special scenarios such as idiopathic ventricular fibrillation, Brugada syndrome, Long and short QT syndrome, early repolarization syndrome, catecholaminergic polymorphic ventricular tachycardia, arrhythmogenic right ventricular cardiomyopathy, and cardiac sarcoidosis have been described as well. VES is a cardiac emergency that requires swift intervention. It is associated with poor short and long-term outcomes. A structured team-based management approach is paramount for the safe and effective treatment of this sick cohort.

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

Europace: 26 Sep 2020; epub ahead of print
Kowlgi GN, Cha YM
Europace: 26 Sep 2020; epub ahead of print | PMID: 32984880
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Impact:
Abstract

The \'double transition\': a novel electrocardiogram sign to discriminate posteroseptal accessory pathways ablated from the right endocardium from those requiring a left-sided or epicardial coronary venous approach.

Pascale P, Hunziker S, Denis A, Gómez Flores JR, ... Jaïs P, Haïssaguerre M
Aims
The precise localization of manifest posteroseptal accessory pathways (APs) often poses diagnostic challenges considering that a small area may encompass AP that may be ablated from the right or left endocardium, or epicardially within the coronary sinus (CS). We sought to explore whether the QRS transition pattern in the precordial lead may help to discriminate the necessary ablation approach.
Methods and results
Consecutive patients who underwent a successful ablation of a single manifest AP over a 5-year period were included. Standard 12-lead electrocardiograms were reviewed. A total of 273 patients were identified. Mean age was 31 ± 15 years and 62% were male. Of the 110 identified posteroseptal AP, 64 were ablated from the right endocardium, 33 from the left endocardium, and 13 inside the CS. While a normal precordial QRS transition was most often observed, a subset of 33 patients presented an atypical \'double transition\' pattern which specifically identified right endocardial AP. The combination of a q wave in V1 with a proportion of the positive QRS component in V1 < V2 > V3, predicted a right endocardial AP with a 100% specificity. In case of a positive QRS sum in V2, this \'double transition\' pattern predicted a posteroseptal right endocardial AP with 99.5% specificity and 44% sensitivity. The positive predictive value was 97%. The only false positive was a midseptal AP. In the case of a negative or isoelectric QRS sum in V2, APs were located more laterally on the tricuspid annulus.
Conclusion
The combination of a q wave in V1 with a double QRS transition pattern in the precordial leads is highly specific of a right endocardial AP and rules out the need for CS or left-sided mapping.

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

Europace: 26 Sep 2020; epub ahead of print
Pascale P, Hunziker S, Denis A, Gómez Flores JR, ... Jaïs P, Haïssaguerre M
Europace: 26 Sep 2020; epub ahead of print | PMID: 32984869
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Impact:
Abstract

A unified theory for the circuit of atrioventricular nodal re-entrant tachycardia.

Katritsis DG

Atrioventricular nodal re-entrant tachycardia (AVNRT) is the most common regular tachycardia in the human, but its exact circuit remains elusive. In this article, recent evidence about the electrophysiological characteristics of AVNRT and new data on the anatomy of the atrioventricular node, are discussed. Based on this information, a novel, unified theory for the nature of the circuit of the tachycardia is presented.

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

Europace: 25 Sep 2020; epub ahead of print
Katritsis DG
Europace: 25 Sep 2020; epub ahead of print | PMID: 32978626
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Impact:
Abstract

Screening for atrial fibrillation: predicted sensitivity of short, intermittent electrocardiogram recordings in an asymptomatic at-risk population.

Quer G, Freedman B, Steinhubl SR
Aims
Screening for asymptomatic atrial fibrillation (AF) could prevent strokes and save lives, but the AF burden of those detected can impact prognosis. New technologies enable continuous monitoring or intermittent electrocardiogram (ECG) snapshots, however, the relationship between AF detection rates and the burden of AF found with intermittent strategies is unknown. We simulated the likelihood of detecting AF using real-world 2-week continuous ECG recordings and developed a generalizable model for AF detection strategies.
Methods and results
From 1738 asymptomatic screened individuals, ECG data of 69 individuals (mean age 76.3, median burden 1.9%) with new AF found during 14 days continuous monitoring were used to simulate 30 seconds ECG snapshots one to four times daily for 14 days. Based on this simulation, 35-66% of individuals with AF would be detected using intermittent screening. Twice-daily snapshots for 2 weeks missed 48% of those detected by continuous monitoring, but mean burden was 0.68% vs. 4% in those detected (P < 0.001). In a cohort of 6235 patients (mean age 69.2, median burden 4.6%) with paroxysmal AF during clinically indicated monitoring, simulated detection rates were 53-76%. The Markovian model of AF detection using mean episode duration and mean burden simulated actual AF detection with ≤9% error across the range of screening frequencies and durations.
Conclusion
Using twice-daily ECG snapshots over 2 weeks would detect only half of individuals discovered to have AF by continuous recordings, but AF burden of those missed was low. A model predicting AF detection, validated using real-world data, could assist development of optimized AF screening programmes.

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

Europace: 29 Sep 2020; epub ahead of print
Quer G, Freedman B, Steinhubl SR
Europace: 29 Sep 2020; epub ahead of print | PMID: 32995870
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Impact:
Abstract

Relation of outcomes to ABC (Atrial Fibrillation Better Care) pathway adherent care in European patients with atrial fibrillation: an analysis from the ESC-EHRA EORP Atrial Fibrillation General Long-Term (AFGen LT) Registry.

Proietti M, Lip GYH, Laroche C, Fauchier L, ... Boriani G,
Aims
There has been an increasing focus on integrated, multidisciplinary, and holistic care in the treatment of atrial fibrillation (AF). The \'Atrial Fibrillation Better Care\' (ABC) pathway has been proposed to streamline integrated care in AF. We evaluated the impact on outcomes of an ABC adherent management in a contemporary real-life European-wide AF cohort.
Methods and results
Patients enrolled in the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry with baseline data to evaluate ABC criteria and available follow-up data were considered for this analysis. Among the original 11 096 AF patients enrolled, 6646 (59.9%) were included in this analysis, of which 1996 (30.0%) managed as ABC adherent. Patients adherent to ABC care had lower CHA2DS2-VASc and HAS-BLED scores (mean ± SD, 2.68 ± 1.57 vs. 3.07 ± 1.90 and 1.26 ± 0.93 vs. 1.58 ± 1.12, respectively; P < 0.001). At 1-year follow-up, patients managed adherent to ABC pathway compared to non-adherent ones had a lower rate of any thromboembolic event (TE)/acute coronary syndrome (ACS)/cardiovascular (CV) death (3.8% vs. 7.6%), CV death (1.9% vs. 4.8%), and all-cause death (3.0% vs. 6.4%) (all P < 0.0001). On Cox multivariable regression analysis, ABC adherent care showed an association with a lower risk of any TE/ACS/CV death [hazard ratio (HR): 0.59, 95% confidence interval (CI): 0.44-0.79], CV death (HR: 0.52, 95% CI: 0.35-0.78), and all-cause death (HR: 0.57, 95% CI: 0.43-0.78).
Conclusion
In a large contemporary cohort of European AF patients, a clinical management adherent to ABC pathway for integrated care is associated with a significant lower risk for cardiovascular events, CV death, and all-cause death.

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

Europace: 01 Oct 2020; epub ahead of print
Proietti M, Lip GYH, Laroche C, Fauchier L, ... Boriani G,
Europace: 01 Oct 2020; epub ahead of print | PMID: 33006613
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Impact:
Abstract

Electrophysiology in the time of coronavirus: coping with the great wave.

Li J, Mazzone P, Leung LWM, Lin W, ... Lin J, Gallagher MM
Aims 
To chart the effect of the COVID-19 pandemic on the activity of interventional electrophysiology services in affected regions.
Methods and results 
We reviewed the electrophysiology laboratory records in three affected cities: Wenzhou in China, Milan in Italy, and London in the UK. We inspected catheter lab records and interviewed electrophysiologists in each centre to gather information on the impact of the pandemic on working patterns and on the health of staff members and patients. There was a striking decline in interventional electrophysiology activity in each of the centres. The decline occurred within a week of the recognition of widespread community transmission of the virus in each region and shows a striking correlation with the national figures for new diagnoses of COVID-19 in each case. During the period of restriction, workflow dropped to <5% of normal, consisting of emergency cases only. In two of three centres, electrophysiologists were redeployed to perform emergency work outside electrophysiology. Among the centres studied, only Wenzhou has seen a recovery from the restrictions in activity. Following an intense nationwide programme of public health interventions, local transmission of COVID-19 ceased to be detectable after 18 February allowing the electrophysiology service to resume with a strict testing regime for all patients.
Conclusion 
Interventional electrophysiology is vulnerable to closure in times of great social difficulty including the COVID-19 pandemic. Intense public health intervention can permit suppression of local disease transmission allowing resumption of some normal activity with stringent precautions.

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

Europace: 29 Sep 2020; epub ahead of print
Li J, Mazzone P, Leung LWM, Lin W, ... Lin J, Gallagher MM
Europace: 29 Sep 2020; epub ahead of print | PMID: 32995866
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Impact:
Abstract

Late gadolinium enhancement role in arrhythmic risk stratification of patients with LMNA cardiomyopathy: results from a long-term follow-up multicentre study.

Peretto G, Barison A, Forleo C, Di Resta C, ... Della Bella P, Sala S
Aims
We aimed at addressing the role of late gadolinium enhancement (LGE) in arrhythmic risk stratification of LMNA-associated cardiomyopathy (CMP).
Methods and results
We present data from a multicentre national cohort of patients with LMNA mutations. Of 164 screened cases, we finally enrolled patients with baseline cardiac magnetic resonance (CMR) including LGE sequences [n = 41, age 35 ± 17 years, 51% males, mean left ventricular ejection fraction (LVEF) by echocardiogram 56%]. The primary endpoint of the study was follow-up (FU) occurrence of malignant ventricular arrhythmias [MVA, including sustained ventricular tachycardia (VT), ventricular fibrillation, and appropriate implantable cardioverter-defibrillator (ICD) therapy]. At baseline CMR, 25 subjects (61%) had LGE, with non-ischaemic pattern in all of the cases. Overall, 23 patients (56%) underwent ICD implant. By 10 ± 3 years FU, eight patients (20%) experienced MVA, consisting of appropriate ICD shocks in all of the cases. In particular, the occurrence of MVA in LGE+ vs. LGE- groups was 8/25 vs. 0/16 (P = 0.014). Of note, no significant differences between LGE+ and LGE- patients were found in currently recognized risk factors for sudden cardiac death (male gender, non-missense mutations, baseline LVEF <45% and non-sustained VT), all P-value >0.05.
Conclusions
In LMNA-CMP patients, LGE at baseline CMR is significantly associated with MVA. In particular, as suggested by this preliminary experience, the absence of LGE allowed to rule-out MVA at 10 years mean FU.

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

Europace: 29 Sep 2020; epub ahead of print
Peretto G, Barison A, Forleo C, Di Resta C, ... Della Bella P, Sala S
Europace: 29 Sep 2020; epub ahead of print | PMID: 32995851
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Impact:
Abstract

Predictive role of early recurrence of atrial fibrillation after cryoballoon ablation.

Stabile G, Iacopino S, Verlato R, Arena G, ... Landolina M, Tondo C
Aims
The aims of this study were to determine the rate and the predictors of early recurrences of atrial fibrillation (ERAF) after cryoballoon (CB) ablation and to evaluate whether ERAF correlate with the long-term outcome.
Methods and results
Three thousand, six hundred, and eighty-one consecutive patients (59.9 ± 10.5 years, female 26.5%, and 74.3% paroxysmal AF) were included in the analysis. Atrial fibrillation recurrence, lasting at least 30 s, was collected during and after the 3-month blanking period. Three-hundred and sixteen patients (8.6%) (Group A) had ERAF during the blanking period, and 3365 patients (Group B) had no ERAF. Persistent AF and number of tested anti-arrhythmic drugs ≥2 resulted as significant predictors of ERAF. After a mean follow-up of 16.8 ± 16.4 months, 923/3681 (25%) patients had at least one AF recurrence. The observed freedom from AF recurrence, at 24-month follow-up from procedure, was 25.7% and 64.8% in Groups A and B, respectively (P < 0.001). ERAF, persistent AF, and number of tested anti-arrhythmic drugs ≥2 resulted as significant predictors of AF. In a propensity score matching, the logistic model showed that ERAF 1 month after ablation are the best predictor of long-term AF recurrence (P = 0.042).
Conclusion
In patients undergoing CB ablation for AF, ERAF are rare and are a strong predictor of AF recurrence in the follow-up, above all when occur >30 days after the ablation.

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

Europace: 01 Oct 2020; epub ahead of print
Stabile G, Iacopino S, Verlato R, Arena G, ... Landolina M, Tondo C
Europace: 01 Oct 2020; epub ahead of print | PMID: 33006599
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Impact:
Abstract

Inflammation and adiposity: new frontiers in atrial fibrillation.

Vyas V, Hunter RJ, Longhi MP, Finlay MC

The aetiology of atrial fibrillation (AF) remains poorly understood, despite its growing prevalence and associated morbidity, mortality, and healthcare costs. Obesity is implicated in myriad different disease processes and is now recognized a major risk factor in the pathogenesis of AF. Moreover, the role of distinct adipose tissue depots is a matter of intense scientific interest with the depot directly surrounding the heart-epicardial adipose tissue (EAT) appearing to have the greatest correlation with AF presence and severity. Similarly, inflammation is implicated in the pathophysiology of AF with EAT thought to act as a local depot of inflammatory mediators. These can easily diffuse into atrial tissue with the potential to alter its structural and electrical properties. Various meta-analyses have indicated that EAT size is an independent risk factor for AF with adipose tissue expansion being inevitably associated with a local inflammatory process. Here, we first briefly review adipose tissue anatomy and physiology then move on to the epidemiological data correlating EAT, inflammation, and AF. We focus particularly on discussing the mechanistic basis of how EAT inflammation may precipitate and maintain AF. Finally, we review how EAT can be utilized to help in the clinical management of AF patients and discuss future avenues for research.

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

Europace: 01 Oct 2020; epub ahead of print
Vyas V, Hunter RJ, Longhi MP, Finlay MC
Europace: 01 Oct 2020; epub ahead of print | PMID: 33006596
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Impact:
Abstract

Screen-detected atrial fibrillation predicts mortality in elderly subjects.

Zink MD, Mischke KG, Keszei AP, Rummey C, ... Schulz JB, Marx N
Aims
Current guidelines recommend opportunistic screening for atrial fibrillation (AF) but the prognosis of individuals is unclear. The aim of this investigation is to determine prevalence and 1-year outcome of individuals with screen-detected AF.
Methods and results
We performed a prospective, pharmacy-based single time point AF screening study in 7107 elderly citizens (≥65 years) using a hand-held, single-lead electrocardiogram (ECG) device. Prevalence of AF was assessed, and data on all-cause death and hospitalization for cardiovascular (CV) causes were collected over a median follow-up of 401 (372; 435) days. Mean age of participants was 74 ± 5.9 years, with 58% (N = 4130) of female sex. Automated heart rhythm analyses identified AF in 432 (6.1%) participants, with newly diagnosed AF in 3.6% of all subjects. During follow-up, 62 participants (0.9%) died and 390 (6.0%) were hospitalized for CV causes. Total mortality was 2.3% in participants with a screen-detected AF and 0.8% in subjects with a normal ECG [hazard ratio (HR) 2.94; 95% confidence interval (CI) 1.49-5.78; P = 0.002]; hospitalization for CV causes occurred in 10.6% and 5.5%, respectively (HR 2.08; 95% CI 1.52-2.84; P < 0.001). Compared with subjects without a history of AF at baseline and a normal ECG, participants with newly diagnosed or known AF had a significantly higher mortality risk with HRs of 2.64 (95% CI 1.05-6.66; P = 0.04) and 2.68 (95% CI 1.44-4.97; P = 0.002), respectively. After multivariable adjustment, screen-detected AF remained a significant predictor of death or hospitalization for CV causes.
Conclusion
Pharmacy-based, automated AF screening in elderly citizens identified subjects with unknown AF and an excess mortality risk over the next year.

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

Europace: 05 Oct 2020; epub ahead of print
Zink MD, Mischke KG, Keszei AP, Rummey C, ... Schulz JB, Marx N
Europace: 05 Oct 2020; epub ahead of print | PMID: 33020819
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Impact:
Abstract

Association of anticoagulant therapy with risk of dementia among patients with atrial fibrillation.

Kim D, Yang PS, Jang E, Yu HT, ... Lip GYH, Joung B
Aims
To investigate the risk of dementia in atrial fibrillation (AF) patients treated with different oral anticoagulants (OACs).
Methods and results
This observational, population-based cohort study enrolled 53 236 dementia-free individuals with non-valvular AF who were aged ≥50 years and newly prescribed OACs from 1 January 2013 to 31 December 2016 from the Korean National Health Insurance Service database. Propensity score matching was used to compare the rates of dementia between users of non-vitamin K antagonist oral anticoagulant (NOAC) (dabigatran, rivaroxaban, and apixaban) and warfarin and to compare each individual NOAC with warfarin. Propensity score weighting analyses were also performed. In the study population (41.3% women; mean age: 70.7 years), 2194 had a diagnosis of incident dementia during a mean follow-up of 20.2 months. Relative to propensity-matched warfarin users, NOAC users tended to be at lower risk of dementia [hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.69-0.90]. When comparing individual NOACs with warfarin, all the three NOACs were associated with lower dementia risk. In pairwise comparisons among NOACs, rivaroxaban was associated with decreased dementia risk, compared with dabigatran (HR 0.83, 95% CI 0.74-0.92). Supplemental propensity-weighted analyses showed consistent protective associations of NOACs with dementia relative to warfarin. The associations were consistent irrespectively of age, sex, stroke, and vascular disease and more prominent in standard dose users of NOAC.
Conclusion
In this propensity-matched and -weighted analysis using a real-world population-based cohort, use of NOACs was associated with lower dementia risk than use of warfarin among non-valvular AF patients initiating OAC treatment.

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

Europace: 15 Oct 2020; epub ahead of print
Kim D, Yang PS, Jang E, Yu HT, ... Lip GYH, Joung B
Europace: 15 Oct 2020; epub ahead of print | PMID: 33063123
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Impact:
Abstract

Avoiding implant complications in cardiac implantable electronic devices: what works?

Frausing MHJP, Kronborg MB, Johansen JB, Nielsen JC

Nearly one in ten patients experience complications in relation to cardiac implantable electronic device (CIED) implantations. CIED complications have serious implications for the patients and for the healthcare system. In light of the rising rates of new implants and consistent rate of complications, primary prevention remains a major concern. To guide future efforts, we sought to review the evidence base underlying common preventive actions made during a primary CIED implantation.

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

Europace: 15 Oct 2020; epub ahead of print
Frausing MHJP, Kronborg MB, Johansen JB, Nielsen JC
Europace: 15 Oct 2020; epub ahead of print | PMID: 33063088
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Impact:
Abstract

Incidence, characteristics, determinants, and prognostic impact of recurrent syncope.

Zimmermann T, du Fay de Lavallaz J, Nestelberger T, Gualandro DM, ... Mueller C,
Aims 
The aim of this study is to characterize recurrent syncope, including sex-specific aspects, and its impact on death and major adverse cardiovascular events (MACE).
Methods and results
We characterized recurrent syncope in a large international multicentre study, enrolling patients ≥40 years presenting to the emergency department (ED) with a syncopal event within the last 12 h. Syncope aetiology was centrally adjudicated by two independent cardiologists using all information becoming available during syncope work-up and long-term follow-up. Overall, 1790 patients were eligible for this analysis. Incidence of recurrent syncope was 20% [95% confidence interval (CI) 18-22%] within the first 24 months. Patients with an adjudicated final diagnosis of cardiac syncope (hazard ratio (HR) 1.50, 95% CI 1.11-2.01) or syncope with an unknown aetiology even after central adjudication (HR 2.11, 95% CI 1.54-2.89) had an increased risk for syncope recurrence. Least Absolute Shrinkage and Selection Operator regression fit on all patient information available early in the ED identified >3 previous episodes of syncope as the only independent predictor for recurrent syncope (HR 2.13, 95% CI 1.64-2.75). Recurrent syncope carried an increased risk for death (HR 1.87, 95% CI 1.26-2.77) and MACE (HR 2.69, 95% CI 2.02-3.59) over 24 months of follow-up, however, with a time-dependent effect. These findings were confirmed in a sensitivity analysis excluding patients with syncope recurrence or MACE before or during ED evaluation.
Conclusion 
Recurrence rates of syncope are substantial and vary depending on syncope aetiology. Importantly, recurrent syncope carries a time-dependent increased risk for death and MACE.
Trial registration
BAsel Syncope EvaLuation (BASEL IX, ClinicalTrials.gov registry number NCT01548352).

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

Europace: 09 Oct 2020; epub ahead of print
Zimmermann T, du Fay de Lavallaz J, Nestelberger T, Gualandro DM, ... Mueller C,
Europace: 09 Oct 2020; epub ahead of print | PMID: 33038231
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Impact:
Abstract

Arrhythmogenic substrate detection in chronic ischaemic patients undergoing ventricular tachycardia ablation using multidetector cardiac computed tomography: compared evaluation with cardiac magnetic resonance.

Jáuregui B, Soto-Iglesias D, Zucchelli G, Penela D, ... Mont L, Berruezo A
Aims
Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) permits characterizing ischaemic scars, detecting heterogeneous tissue channels (HTCs) which constitute the arrhythmogenic substrate (AS). Late gadolinium enhancement cardiac magnetic resonance also improves the arrhythmia-free survival when used to guide ventricular tachycardia (VT) substrate ablation. However, its availability may be limited. We sought to evaluate the performance of multidetector cardiac computed tomography (MDCT) imaging in identifying HTCs detected by LGE-CMR in ischaemic patients undergoing VT substrate ablation.
Methods and results
Thirty ischaemic patients undergoing both LGE-CMR and MDCT before VT substrate ablation were included. Using a dedicated post-processing software, two blinded operators, assigned either to LGE-CMR or MDCT analysis, characterized the presence of CMR and computed tomography (CT) channels, respectively. Cardiac magnetic resonance channels were classified as endocardial (layers < 50%), epicardial (layers ≥ 50%), or transmural. Cardiac magnetic resonance- vs. CT-channel concordance was considered when showing the same orientation and American Heart Association (AHA) segment. Mean age was 69 ± 10 years; 90% were male. Mean left ventricular ejection fraction was 35 ± 10%. All patients had CMR channels (n = 76), whereas only 26/30 (86.7%) had CT channels (n = 91). Global sensitivity (Se) and positive predictive values for detecting CMR channels were 61.8% and 51.6%, respectively. MDCT performance improved in patients with epicardial CMR channels (Se 80.5%) and transmural scars (Se 72.2%). In 4/11 (36%) patients with subendocardial myocardial infarction (MI), MDCT was unable to identify the AS.
Conclusions
Compared to LGE-CMR, myocardial wall thickness assessment using MDCT fails to detect the presence of AS in 36% of patients with subendocardial MI, showing modest sensitivity identifying HTCs but a better performance in patients with transmural scars.

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

Europace: 09 Oct 2020; epub ahead of print
Jáuregui B, Soto-Iglesias D, Zucchelli G, Penela D, ... Mont L, Berruezo A
Europace: 09 Oct 2020; epub ahead of print | PMID: 33038230
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Impact:
Abstract

Self-reported treatment burden in patients with atrial fibrillation: quantification, major determinants, and implications for integrated holistic management of the arrhythmia.

Potpara TS, Mihajlovic M, Zec N, Marinkovic M, ... Mujovic N, Stankovic GR
Aims 
Treatment burden (TB) refers to self-perceived cumulative work patients do to manage their health. Using validated tools, TB has been documented in several chronic conditions, but not atrial fibrillation (AF). We measured TB and analysed its determinants and impact on quality of life (QoL) in an AF cohort.
Methods and results 
A single-centre study prospectively included consecutive adult AF patients and non-AF controls managed from 1 April to 21 June 2019, who voluntarily and anonymously answered the TB questionnaire (TBQ) and 5-item EQ-5D QoL questionnaire; TB was calculated as a sum of TBQ points (maximum 170) and expressed as proportion of the maximum value. Of 514 participants, 331 (64.4%) had AF. The mean self-reported TB was 27.6% among AF patients and 24.3% among controls, P = 0.011. The mean TB was significantly higher in patients taking vitamin K antagonists (VKAs) vs. those taking non-VKA antagonist oral anticoagulants (NOAC; 29.5% vs. 24.7%, P = 0.006). The highest item-specific TB was reported for healthcare system organization-related items (e.g. visit appointment), diet, and physical activity modifications. On multivariable analyses, female sex, younger age, and permanent AF were associated with a higher TB, whereas NOACs and electrical AF cardioversion exhibited an inverse association; TB was an independent predictor of decreased QoL (all P < 0.05).
Conclusion 
Our study provided clinically relevant insights into self-perceived TB among AF patients. Approximately one in four patients with AF have a high TB. Specific AF treatments and optimization of healthcare system-required patient activities may reduce the self-perceived TB in AF patients.

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

Europace: 09 Oct 2020; epub ahead of print
Potpara TS, Mihajlovic M, Zec N, Marinkovic M, ... Mujovic N, Stankovic GR
Europace: 09 Oct 2020; epub ahead of print | PMID: 33038228
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Impact:
Abstract

Risk of syncopal recurrences in patients treated with permanent pacing for bradyarrhythmic syncope: role of correlation between symptoms and electrocardiogram findings.

Palmisano P, Pellegrino PL, Ammendola E, Ziacchi M, ... Accogli M, Dell\'Era G
Aims 
To evaluate the risk of syncopal recurrences after pacemaker implantation in a population of patients with syncope of suspected bradyarrhythmic aetiology.
Methods and results 
Prospective, multicentre, observational registry enrolling 1364 consecutive patients undergoing pacemaker implantation for syncope of bradyarrhythmic aetiology (proven or presumed). Before pacemaker implantation, all patients underwent a cardiac work-up in order to establish the bradyarrhythmic aetiology of syncope. According to the results of the diagnostic work-up, patients were divided into three groups: Group A, patients in whom a syncope-electrocardiogram (ECG) correlation was established (n = 329, 24.1%); Group B, those in whom clinically significant bradyarrhythmias were detected without a documented syncope-ECG correlation (n = 877, 64.3%); and Group C, those in whom bradyarrhythmias were not detected and the bradyarrhythmic origin of syncope remained presumptive (n = 158, 11.6%). During a median follow-up of 50 months, 213 patients (15.6%) reported at least one syncopal recurrence. Patients in Groups B and C showed a significantly higher risk of syncopal recurrences than those in Group A [hazard ratios (HRs): 1.60 and 2.66, respectively, P < 0.05]. Failure to establish a syncope-ECG correlation during diagnostic work-up before pacemaker implantation was an independent predictor of syncopal recurrence on multivariate analysis (HR: 1.90; P = 0.002).
Conclusion
In selecting patients with syncope of suspected bradyarrhythmic aetiology for pacemaker implantation, establishing a correlation between syncope and bradyarrhythmias maximizes the efficacy of pacing and reduces the risk of syncopal recurrences.

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

Europace: 09 Oct 2020; epub ahead of print
Palmisano P, Pellegrino PL, Ammendola E, Ziacchi M, ... Accogli M, Dell'Era G
Europace: 09 Oct 2020; epub ahead of print | PMID: 33038220
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Impact:
Abstract

Idiopathic ventricular fibrillation: the ongoing quest for diagnostic refinement.

Conte G, Giudicessi JR, Ackerman MJ

Prior to the recognition of distinct clinical entities, such as Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, and long QT syndrome, all sudden cardiac arrest (SCA) survivors with ventricular fibrillation (VF) and apparently structurally normal hearts were labelled as idiopathic ventricular fibrillation (IVF). Over the last three decades, the definition of IVF has changed substantially, mostly as result of the identification of the spectrum of SCA-predisposing genetic heart diseases (GHDs), and the molecular evidence, by post-mortem genetic analysis (aka, the molecular autopsy), of cardiac channelopathies as the pathogenic basis for up to 35% of unexplained cases of sudden cardiac death (SCD) in the young. The evolution of the definition of IVF over time has led to a progressively greater awareness of the need for an extensive diagnostic assessment in unexplained SCA survivors. Nevertheless, GHDs are still underdiagnosed among SCA survivors, due to the underuse of pharmacological challenges (i.e. sodium channel blocker test), misrecognition of electrocardiogram (ECG) abnormalities/patterns (i.e. early repolarization pattern or exercise-induced ventricular bigeminy) or errors in the measurement of ECG parameters (e.g. the heart-rate corrected QT interval). In this review, we discuss the epidemiology, diagnostic approaches, and the controversies related to role of the genetic background in unexplained SCA survivors with a default diagnosis of IVF.

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

Europace: 09 Oct 2020; epub ahead of print
Conte G, Giudicessi JR, Ackerman MJ
Europace: 09 Oct 2020; epub ahead of print | PMID: 33038214
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Impact:
Abstract

Safety of smartwatches and their chargers in patients with cardiac implantable electronic devices.

Tzeis S, Asvestas D, Moraitis N, Vardas EP, ... Nikita KS, Vardas P
Aims
Cardiac implantable electronic devices (CIEDs) are susceptible to electromagnetic interference (EMI). Smartwatches and their chargers could be a possible source of EMI. We sought to assess whether the latest generation smartwatches and their chargers interfere with proper CIED function.
Methods and results
We included consecutive CIED recipients in two centres. We tested two latest generation smartwatches (Apple Watch and Samsung Galaxy Watch) and their charging cables for potential EMI. The testing was performed under continuous electrocardiogram recording and real-time device telemetry, with nominal and \'worst-case\' settings. In vitro magnetic field measurements were performed to assess the emissions from the tested devices, initially in contact with the probe and then at a distance of 10 cm and 20 cm. In total, 171 patients with CIEDs (71.3% pacemakers-28.7% implantable cardioverter-defibrillators) from five manufacturers were enrolled (63.2% males, 74.8 ± 11.4 years), resulting in 684 EMI tests. No EMI was identified in any patient either under nominal or \'worst-case scenario\' programming. The peak magnetic flux density emitted by the smartwatches was similar to the background noise level (0.81 μT) even when in contact with the measuring probe. The respective values for the chargers were 4.696 μΤ and 4.299 μΤ for the Samsung and Apple chargers, respectively, which fell at the background noise level when placed at 20 cm and 10 cm, respectively.
Conclusion
Two latest generation smartwatches and their chargers resulted in no EMI in CIED recipients. The absence of EMI in conjunction with the extremely low intensity of magnetic fields emitted by these devices support the safety of their use by CIED patients.

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

Europace: 09 Oct 2020; epub ahead of print
Tzeis S, Asvestas D, Moraitis N, Vardas EP, ... Nikita KS, Vardas P
Europace: 09 Oct 2020; epub ahead of print | PMID: 33038213
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Impact:
Abstract

Low-voltage bridge strategy to guide cryoablation of typical and atypical atrioventricular nodal re-entry tachycardia in children: mid-term outcomes in a large cohort of patients.

Drago F, Calvieri C, Russo MS, Remoli R, ... Allegretti G, Silvetti MS
Aims
In the current literature, results of the low-voltage bridge (LVB) ablation strategy for the definitive treatment of atrioventricular nodal re-entry tachycardia (AVNRT) seem to be encouraging also in children. The aims of this study were (i) to prospectively evaluate the mid-term efficacy of LVB ablation in a very large cohort of children with AVNRT, and (ii) to identify electrophysiological factors associated with recurrence.
Methods and results
One hundred and eighty-four children (42% male, mean age 13 ± 4 years) with AVNRT underwent transcatheter cryoablation guided by voltage mapping of the Koch\'s triangle. Acute procedural success was 99.2% in children showing AVNRT inducibility at the electrophysiological study. The overall recurrence rate was 2.7%. The presence of two LVBs, a longer fluoroscopy time and the presence of both typical and atypical AVNRT, were found to be significantly associated with an increased recurrence rate during mid-term follow-up. Conversely, there was no significant association between recurrences and patient\'s age, type of LVB, lesion length, number of cryolesions or catheter tip size.
Conclusion
The LVB ablation strategy is very effective in AVNRT treatment in children. Recurrences are related to the complexity of the arrhythmogenic substrate.

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

Europace: 09 Oct 2020; epub ahead of print
Drago F, Calvieri C, Russo MS, Remoli R, ... Allegretti G, Silvetti MS
Europace: 09 Oct 2020; epub ahead of print | PMID: 33038208
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Impact:
Abstract

Classification of sinus rhythm single potential morphology in patients with mitral valve disease.

van Schie MS, Starreveld R, Roos-Serote MC, Taverne YJHJ, ... Bogers AJJC, de Groot NMS
Aims
The morphology of unipolar single potentials (SPs) contains information on intra-atrial conduction disorders and possibly the substrate underlying atrial fibrillation (AF). This study examined the impact of AF episodes on features of SP morphology during sinus rhythm (SR) in patients with mitral valve disease.
Methods and results
Intraoperative epicardial mapping (interelectrode distance 2 mm) of the right and left atrium (RA, LA), Bachmann\'s bundle (BB), and pulmonary vein area (PVA) was performed in 67 patients (27 male, 67 ± 11 years) with or without a history of paroxysmal AF (PAF). Unipolar SPs were classified according to their differences in relative R- and S-wave amplitude ratios. A clear predominance of S-waves was observed at BB and the RA in both the no AF and PAF groups (BB 88.8% vs. 85.9%, RA 92.1% vs. 85.1%, respectively). Potential voltages at the RA, BB, and PVA were significantly lower in the PAF group (P < 0.001 for each) and were mainly determined by the size of the S-waves amplitudes. The largest difference in S-wave amplitudes was found at BB; the S-wave amplitude was lower in the PAF group [4.08 (2.45-6.13) mV vs. 2.94 (1.40-4.75) mV; P < 0.001]. In addition, conduction velocity (CV) at BB was lower as well [0.97 (0.70-1.21) m/s vs. 0.89 (0.62-1.16) m/s, P < 0.001].
Conclusion
Though excitation of the atria during SR is heterogeneously disrupted, a history of AF is characterized by decreased SP amplitudes at BB due to loss of S-wave amplitudes and decreased CV. This suggests that SP morphology could provide additional information on wavefront propagation.

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

Europace: 30 Sep 2020; 22:1509-1519
van Schie MS, Starreveld R, Roos-Serote MC, Taverne YJHJ, ... Bogers AJJC, de Groot NMS
Europace: 30 Sep 2020; 22:1509-1519 | PMID: 33033830
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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: 11 Oct 2020; epub ahead of print
Kim M, Yu HT, Kim J, Kim TH, ... Lee MH, Pak HN
Europace: 11 Oct 2020; epub ahead of print | PMID: 33045047
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Impact:
Abstract

Paroxysmal atrial fibrillation with high vs. low arrhythmia burden: atrial remodelling and ablation outcome.

Strisciuglio T, El Haddad M, Debonnaire P, De Pooter J, ... Vandekerckhove Y, Duytschaever M
Aims
The relation between atrial tachyarrhythmia (ATA) burden in paroxysmal atrial fibrillation (AF), atrial remodelling, and efficacy of catheter ablation (CA) is unknown. We investigated whether high vs. low-burden paroxysmal AF patients have distinct clinical characteristics or electro-mechanical properties of the left atrium (LA) and whether burden impacts outcome of CA.
Methods and results
Atrial tachyarrhythmia burden, defined as the percentage of time spent in ATA, was assessed by insertable cardiac monitors in 105 patients before and after CA. Clinical characteristics and electro-mechanical properties of LA were compared between patients with high vs. low ATA burden. Catheter ablation efficacy was assessed by reduction in ATA burden and 1-year freedom from any ATA. Median ATA burden was 2.7% (highest tertile 9.3%). Clinical characteristics and electrical properties of LA (refractoriness, conduction velocity, low voltage) did not differ between high (≥9.3%) vs. low ATA burden (<9.3%) patients. High ATA burden patients had larger LA diameter (46.5 ± 6 vs. 42.5 ± 6mm, P < 0.01), volume (93.8 ± 22 vs. 80.4 ± 21mL, P = 0.01), and lower LA reservoir and contractile strain (19.7 ± 6 vs. 24.7 ± 6%, P < 0.01; 10.3 ± 3 vs. 12.8 ± 4%, P = 0.01). Catheter ablation reduced ATA burden by 100% (100-100) in both groups (P = 1.0). Freedom from ATA after CA was equally high (83% vs. 89%, P = 0.38).
Conclusion
Paroxysmal AF patients with high ATA burden have altered LA mechanical properties, reflected by larger size and impaired function. Despite mechanical remodelling of the atria, they are excellent responders to CA. Most likely the lack of fibrosis and/or advanced electrical remodelling explain why pulmonary veins remain the dominant trigger for AF in this patient cohort.

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

Europace: 31 Jul 2020; 22:1189-1196
Strisciuglio T, El Haddad M, Debonnaire P, De Pooter J, ... Vandekerckhove Y, Duytschaever M
Europace: 31 Jul 2020; 22:1189-1196 | PMID: 32601674
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Impact:
Abstract

Exercise restriction is protective for genotype-positive family members of arrhythmogenic right ventricular cardiomyopathy patients.

Wang W, Tichnell C, Murray BA, Agafonova J, ... Calkins H, James CA
Aims
In arrhythmogenic right ventricular cardiomyopathy (ARVC) patients, exercise worsens disease course, so exercise restriction is recommended. However, recommendations for genotype-positive ARVC family members is incompletely resolved. We aimed to provide evidence for exercise recommendations for genotype-positive ARVC family members.
Methods and results
Arrhythmogenic right ventricular cardiomyopathy family members inheriting a pathogenic desmosomal variant were interviewed about exercise history from age 10. Exercise was characterized by duration, intensity, and dose (duration*intensity). Associations between exercise and (i) diagnosis by 2010 Task Force Criteria and (ii) development of sustained ventricular arrhythmias were examined. The study included 101 family members (age: 40.5 ± 19.3 years, male: 41%, Plakophilin-2 variant: 81%). Forty-four individuals (44%) met diagnostic criteria and 16 (16%) experienced sustained ventricular arrhythmia. Individuals who met diagnostic criteria had significantly higher average exercise duration and dose, but not peak intensity than those who did not. Only one individual who exercised below the American Heart Association recommended minimum (650 metabolic equivalent of task-hours/year) met diagnostic criteria or experienced sustained ventricular arrhythmia as opposed to 50% of individuals who exceeded it (adjusted odds ratio = 0.03, 95% confidence interval 0.003-0.26). The difference in exercise exposure between affected and unaffected individuals was more striking in females than in males. Females who had done high-dose exercise in adolescence had the worst survival free from diagnosis (P < 0.01).
Conclusions
In phenotype-negative ARVC family members with a pathogenic desmosomal variant, athletic activities should be limited, particularly exercise dose. Exercise may play a greater role in promoting disease in female family members.

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

Europace: 31 Jul 2020; 22:1270-1278
Wang W, Tichnell C, Murray BA, Agafonova J, ... Calkins H, James CA
Europace: 31 Jul 2020; 22:1270-1278 | PMID: 32572458
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Impact:
Abstract

Acute and mid-term outcome of ethanol infusion of vein of Marshall for the treatment of perimitral flutter.

Takigawa M, Vlachos K, Martin CA, Bourier F, ... Jaïs P, Derval N
Aims 
We hypothesized that an epicardial approach using ethanol infusion in the vein of Marshall (EIVOM) may improve the result of ablation for perimitral flutter (PMF).
Methods and results 
We studied 103 consecutive patients with PMF undergoing high-resolution mapping. The first 71 were treated with radiofrequency (RF) ablation alone (RF-group), and the next 32 underwent EIVOM followed by RF on the endocardial and epicardial mitral isthmus (EIVOM/RF-group). Contact force was not measured during ablation. Acute and 1-year outcomes were compared. Flutter termination rates were similar between the RF-group (63/71, 88.7%) and EIVOM/RF-group (31/32, 96.8%, P = 0.27). Atrial tachycardia (AT) terminated with EIVOM alone in 22/32 (68.6%) in the EIVOM/RF-group. Bidirectional block of mitral isthmus was always achieved in the EIVOM/RF-group, but significantly less frequently achieved in the RF-group (62/71, 87.3%; P = 0.05). Median RF duration for AT termination/conversion was shorter [0 (0-6) s in the EIVOM/RF-group than 312 (55-610) s in the RF-group, P < 0.0001], as well as for mitral isthmus block in the EIVOM/RF-group [246 (0-663) s] than in the RF-group [900 (525-1310) s, P < 0.0001]. Pericardial effusion was observed in 1/32 (3.2%) in EIVOM/RF-group and 5/71 (7.0%) in RF-group (P = 0.66); two in RF-group required drainage and one of them developed subsequent ischaemic stroke. One-year follow-up demonstrated fewer recurrences in the EIVOM/RF-group [6/32 (18.8%)] than in the RF-group [29/71 (40.8%), P = 0.04]. By multivariate analysis, only EIVOM was significantly associated with less AT recurrence (hazard ratio = 0.35, P = 0.018).
Conclusion 
Ethanol infusion in the vein of Marshall may reduce RF duration required for PMF termination as well as for mitral isthmus block without severe complications, and the mid-term outcome may be improved by this approach.

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

Europace: 31 Jul 2020; 22:1252-1260
Takigawa M, Vlachos K, Martin CA, Bourier F, ... Jaïs P, Derval N
Europace: 31 Jul 2020; 22:1252-1260 | PMID: 32594180
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Impact:
Abstract

Prevalence of sudden arrhythmic death syndrome-related genetic mutations in an Asian cohort of whole genome sequence.

Huang PS, Hsieh CS, Chang SN, Chen JJ, ... Chuang EY, Tsai CT
Aims
Recently, the spectrum of background mutation in the genes implicated in sudden arrhythmic death syndrome (SADS), has been elucidated in the Caucasian populations. However, this information is largely unknown in the Asian populations.
Methods and results
We assessed the background rare variants (minor allele frequency < 0.01) of major SADS genes in whole genome sequence data of 1514 healthy Taiwanese subjects from the Taiwan Biobank. We found up to 45% of healthy subjects have a rare variant in at least one of the major SADS genes. Around 3.44% of healthy subjects had multiple mutations in one or multiple genes. The background mutation rates in long QT syndrome, catecholaminergic polymorphic ventricular tachycardia, and arrhythmogenic right ventricular cardiomyopathy genes were similar, but those in Brugada syndrome (BrS) (SCN5A) and hypertrophic cardiomyopathy (HCM) genes (MYBPC3, MYH7, and TNNT2) were higher, compared to those reported in the Caucasian populations. Furthermore, the rate of incidental pathogenic variant was highest in MYBPC3 gene. Finally, the number of variant was proportional to the exon length of the gene (R2 = 0.486, P = 0.0056) but not related to its functional or evolutionary importance (degree of evolutionary conservation) (R2 = 0.0008, P = 0.9218), suggesting that the mutation was random. The ratio of variant number over exon nucleotide length was highest in MYBPC3, MYH7, and TNNT2 genes.
Conclusion
Unique features of background SADS gene mutation in the Asian populations include higher prevalence of incidental variant in HCM, BrS, and long QT 3 (SCN5A) genes. HCM genes have the highest variant number per exon length.

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

Europace: 31 Jul 2020; 22:1287-1297
Huang PS, Hsieh CS, Chang SN, Chen JJ, ... Chuang EY, Tsai CT
Europace: 31 Jul 2020; 22:1287-1297 | PMID: 32594176
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Impact:
Abstract

Association of beta-blockers and first-registered heart rhythm in out-of-hospital cardiac arrest: real-world data from population-based cohorts across two European countries.

Barcella CA, Eroglu TE, Hulleman M, Granfeldt A, ... Tan HL,
Aims
Conflicting results have been reported regarding the effect of beta-blockers on first-registered heart rhythm in out-of-hospital cardiac arrest (OHCA). We aimed to establish whether the use of beta-blockers influences first-registered rhythm in OHCA.
Methods and results
We included patients with OHCA of presumed cardiac cause from two large independent OHCA-registries from Denmark and the Netherlands. Beta-blocker use was defined as exposure to either non-selective beta-blockers, β1-selective beta-blockers, or α-β-dual-receptor blockers within 90 days prior to OHCA. We calculated odds ratios (ORs) for the association of beta-blockers with first-registered heart rhythm using multivariable logistic regression. We identified 23 834 OHCA-patients in Denmark and 1584 in the Netherlands: 7022 (29.5%) and 519 (32.8%) were treated with beta-blockers, respectively. Use of non-selective beta-blockers, but not β1-selective blockers, was more often associated with non-shockable rhythm than no use of beta-blockers [Denmark: OR 1.93, 95% confidence interval (CI) 1.48-2.52; the Netherlands: OR 2.52, 95% CI 1.15-5.49]. Non-selective beta-blocker use was associated with higher proportion of pulseless electrical activity (PEA) than of shockable rhythm (OR 2.38, 95% CI 1.01-5.65); the association with asystole was of similar magnitude, although not statistically significant compared with shockable rhythm (OR 2.34, 95% CI 0.89-6.18; data on PEA and asystole were only available in the Netherlands). Use of α-β-dual-receptor blockers was significantly associated with non-shockable rhythm in Denmark (OR 1.21; 95% CI 1.03-1.42) and not significantly in the Netherlands (OR 1.37; 95% CI 0.61-3.07).
Conclusion
Non-selective beta-blockers, but not β1-selective beta-blockers, are associated with non-shockable rhythm in OHCA.

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

Europace: 31 Jul 2020; 22:1206-1215
Barcella CA, Eroglu TE, Hulleman M, Granfeldt A, ... Tan HL,
Europace: 31 Jul 2020; 22:1206-1215 | PMID: 32594166
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Impact:
Abstract

Mortality and cardiac resynchronization therapy with or without defibrillation in primary prevention.

Gras M, Bisson A, Bodin A, Herbert J, ... Clementy N, Fauchier L
Aims 
Cardiac resynchronization therapy with (CRTD) or without (CRTP) defibrillator is recommended in selected patient with systolic chronic heart failure and wide QRS. There is no guideline firmly indicating choice between CRTP and CRTD in primary prevention, particularly in older patients.
Methods and results 
Based on the French administrative hospital-discharge database, information was collected from 2010 to 2017 for all patients implanted with CRTP or CRTD in primary prevention. Outcome analyses were undertaken in the total study population and in propensity-matched samples. During follow-up (913 days, SD 841, median 701, IQR 151-1493), 45 697 patients were analysed (CRTP 19 266 and CRTD 26 431). Incidence rate (%patient/year) of all-cause mortality was higher in CRTP patients (11.6%) than in CRTD patients (6.8%) [hazard ratio (HR) 1.70, 95% confidence interval (CI) 1.63-1.76, P < 0.001]. After propensity-matched analyses, mortality of patients over 75 years old with non-ischaemic cardiomyopathy (NICM) was not different with CRTP and CRTD (HR 0.93, 95% CI 0.80-1.09, P = 0.39). The CRTP patients under 75 years old with NICM had a higher mortality than CRTD patients (HR 1.22, 95% CI 1.03-1.45, P = 0.02). Mortality rate was also higher with CRTP than with CRTD irrespectively of age in patients with ischaemic cardiomyopathy (ICM) (<75 years old: HR 1.22, 95% CI 1.08-1.37, P = 0.01; ≥75 years old: HR 1.13, 95% CI 1.04-1.22, P = 0.003).
Conclusion 
In this real-life study, CRTD was associated with a significantly lower all-cause mortality than CRTP in patients with ICM and in patients with NICM under 75 years old. Patients over 75 years old with NICM did not have lower mortality with primary prevention CRTD implantation.

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

Europace: 31 Jul 2020; 22:1224-1233
Gras M, Bisson A, Bodin A, Herbert J, ... Clementy N, Fauchier L
Europace: 31 Jul 2020; 22:1224-1233 | PMID: 32594143
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Impact:
Abstract

In silico pace-mapping: prediction of left vs. right outflow tract origin in idiopathic ventricular arrhythmias with patient-specific electrophysiological simulations.

Doste R, Sebastian R, Gomez JF, Soto-Iglesias D, ... Penela D, Camara O
Aims
A pre-operative non-invasive identification of the site of origin (SOO) of outflow tract ventricular arrhythmias (OTVAs) is important to properly plan radiofrequency ablation procedures. Although some algorithms based on electrocardiograms (ECGs) have been developed to predict left vs. right ventricular origins, their accuracy is still limited, especially in complex anatomies. The aim of this work is to use patient-specific electrophysiological simulations of the heart to predict the SOO in OTVA patients.
Methods and results
An in silico pace-mapping procedure was designed and used on 11 heart geometries, generating for each case simulated ECGs from 12 clinically plausible SOO. Subsequently, the simulated ECGs were compared with patient ECG data obtained during the clinical tachycardia using the 12-lead correlation coefficient (12-lead ρ). Left ventricle (LV) vs. right ventricle (RV) SOO was estimated by computing the LV/RV ratio for each patient, obtained by dividing the average 12-lead ρ value of the LV- and RV-SOO simulated ECGs, respectively. Simulated ECGs that had virtual sites close to the ablation points that stopped the arrhythmia presented higher correlation coefficients. The LV/RV ratio correctly predicted LV vs. RV SOO in 10/11 cases; 1.07 vs. 0.93 P < 0.05 for 12-lead ρ.
Conclusion
The obtained results demonstrate the potential of the developed in silico pace-mapping technique to complement standard ECG for the pre-operative planning of complex ventricular arrhythmias.

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

Europace: 31 Aug 2020; 22:1419-1430
Doste R, Sebastian R, Gomez JF, Soto-Iglesias D, ... Penela D, Camara O
Europace: 31 Aug 2020; 22:1419-1430 | PMID: 32607538
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Impact:
Abstract

Mobile health applications for the detection of atrial fibrillation: a systematic review.

Lopez Perales CR, Van Spall HGC, Maeda S, Jimenez A, ... Muser D, Casado Arroyo R
Aims
Atrial fibrillation (AF) is the most common sustained arrhythmia and an important risk factor for stroke and heart failure. We aimed to conduct a systematic review of the literature and summarize the performance of mobile health (mHealth) devices in diagnosing and screening for AF.
Methods and results
We conducted a systematic search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. Forty-three studies met the inclusion criteria and were divided into two groups: 28 studies aimed at validating smart devices for AF diagnosis, and 15 studies used smart devices to screen for AF. Evaluated technologies included smartphones, with photoplethysmographic (PPG) pulse waveform measurement or accelerometer sensors, smartbands, external electrodes that can provide a smartphone single-lead electrocardiogram (iECG), such as AliveCor, Zenicor and MyDiagnostick, and earlobe monitor. The accuracy of these devices depended on the technology and the population, AliveCor and smartphone PPG sensors being the most frequent systems analysed. The iECG provided by AliveCor demonstrated a sensitivity and specificity between 66.7% and 98.5% and 99.4% and 99.0%, respectively. The PPG sensors detected AF with a sensitivity of 85.0-100% and a specificity of 93.5-99.0%. The incidence of newly diagnosed arrhythmia ranged from 0.12% in a healthy population to 8% among hospitalized patients.
Conclusion
Although the evidence for clinical effectiveness is limited, these devices may be useful in detecting AF. While mHealth is growing in popularity, its clinical, economic, and policy implications merit further investigation. More head-to-head comparisons between mHealth and medical devices are needed to establish their comparative effectiveness.

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

Europace: 11 Oct 2020; epub ahead of print
Lopez Perales CR, Van Spall HGC, Maeda S, Jimenez A, ... Muser D, Casado Arroyo R
Europace: 11 Oct 2020; epub ahead of print | PMID: 33043358
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Impact:
Abstract

Magnetic resonance-guided re-ablation for atrial fibrillation is associated with a lower recurrence rate: a case-control study.

Quinto L, Cozzari J, Benito E, Alarcón F, ... Guasch E, Mont L
Aims
Our aim was to analyse whether using delayed enhancement cardiac magnetic resonance imaging (DE-CMR) to localize veno-atrial gaps in atrial fibrillation (AF) redo ablation procedures improves outcomes during follow-up.
Methods and results
We conducted a case-control study with 35 consecutive patients undergoing a DE-CMR-guided Repeat-pulmonary vein isolation (Re-PVI) procedure. Those with more extensive ablations (e.g. roof lines, box) were excluded. Patients were matched for age, sex, AF pattern, and left atrial dimension with 35 patients who had undergone a conventional Re-PVI procedure guided with a three dimensional (3D)-navigation system. Procedural characteristics were recorded, and patients were followed for 24 months in a specialized outpatient clinic. The primary endpoint was freedom from recurrent AF, atrial tachycardia, or flutter. The duration of CMR-guided procedures was shorter compared to the conventional group (161 ± 52 vs. 195 ± 72 min, respectively, P = 0.049), with no significant differences in fluoroscopy or total radiofrequency time. At the 2-year follow-up, more patients in the DE-CMR-guided group remained free from recurrences compared with the conventional group (70% vs. 39%, respectively, P = 0.007). In univariate Cox-regression analyses, AF pattern [persistent AF, hazard ratio (HR) 2.66 (1.27-5.46), P = 0.006] and the use of DE-CMR [HR 0.36 (0.17-0.79), P = 0.009] predicted recurrences during follow-up; both factors remained independent predictors in multivariate analyses.
Conclusion
The substrate characterization provided by DE-CMR facilitates the identification of anatomical veno-atrial gaps and associates with shorter procedures and better clinical outcomes in repeated AF ablation procedures.

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

Europace: 15 Oct 2020; epub ahead of print
Quinto L, Cozzari J, Benito E, Alarcón F, ... Guasch E, Mont L
Europace: 15 Oct 2020; epub ahead of print | PMID: 33063124
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Impact:
Abstract

Prospective use of ablation index for the ablation of right ventricle outflow tract premature ventricular contractions: a proof of concept study.

Gasperetti A, Sicuso R, Dello Russo A, Zucchelli G, ... Tondo C, Casella M
Aims
Radiofrequency catheter ablation (RFCA) represents an effective option for idiopathic premature ventricular contractions (PVCs) treatment. Ablation Index (AI) is a novel ablation marker incorporating RF power, contact force, and time of delivery into a single weighted formula. Data regarding AI-guided PVCs RFCA are currently lacking. Aim of the study was to compare AI-guided and standard RFCA outcomes in patients with PVCs originating from the right ventricle outflow tract (RVOT).
Methods and results
Consecutive patients undergoing AI-guided RFCA of RVOT idiopathic PVCs were prospectively enrolled. Radiofrequency catheter ablation was performed following per-protocol target cut-offs of AI, depending on targeted area (RVOT free wall AI cut-off: 590; RVOT septum AI cut-off: 610). A multi-centre cohort of propensity-matched (age, sex, ejection fraction, and PVC site) patients undergoing standard PVCs RFCA was used as a comparator. Sixty AI-guided patients (44.2 ± 18.0 years old, 58% male, left ventricular ejection fraction 56.2 ± 3.8%) were enrolled; 34 (57%) were ablated in RVOT septum and 26 (43%) patients in the RVOT free wall area. Propensity match with 60 non-AI-guided patients was performed. Acute outcomes and complications resulted comparable. At 6 months, arrhythmic recurrence was more common in non-AI-guided patients whether in general (28% vs. 7% P = 0.003) or by ablated area (RVOT free wall: 27% vs. 4%, P = 0.06; RVOT septum 29% vs. 9% P = 0.05). Ablation Index guidance was associated with improved survival from arrhythmic recurrence [overall odds ratio 6.61 (1.95-22.35), P = 0.001; RVOT septum 5.99 (1.21-29.65), P = 0.028; RVOT free wall 11.86 (1.12-124.78), P = 0.039].
Conclusion
Ablation Index-guidance in idiopathic PVCs ablation was associated with better arrhythmic outcomes at 6 months of follow-up.

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

Europace: 15 Oct 2020; epub ahead of print
Gasperetti A, Sicuso R, Dello Russo A, Zucchelli G, ... Tondo C, Casella M
Europace: 15 Oct 2020; epub ahead of print | PMID: 33063099
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Impact:
Abstract

Cardioversion of atrial fibrillation and atrial flutter revisited: current evidence and practical guidance for a common procedure.

Brandes A, Crijns HJGM, Rienstra M, Kirchhof P, ... Pedersen KB, Van Gelder IC

Cardioversion is widely used in patients with atrial fibrillation (AF) and atrial flutter when a rhythm control strategy is pursued. We sought to summarize the current evidence on this important area of clinical management of patients with AF including electrical and pharmacological cardioversion, peri-procedural anticoagulation and thromboembolic complications, success rate, and risk factors for recurrence to give practical guidance.

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

Europace: 31 Jul 2020; 22:1149-1161
Brandes A, Crijns HJGM, Rienstra M, Kirchhof P, ... Pedersen KB, Van Gelder IC
Europace: 31 Jul 2020; 22:1149-1161 | PMID: 32337542
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Impact:
Abstract

Implication of the distinctive bipolar intracardiac electrograms for ventricular arrhythmias arising from different regions of ventricular outflow tract.

Li J, Lin W, Zheng C, Zhang C, Yu J, Lin J
Aims
To investigate the characteristics of bipolar intracardiac electrograms (bi-EGMs) in target sites of ventricular arrhythmias (VAs) originating from different regions of ventricular outflow tract (VOT).
Methods and results
Two hundred and seventy patients undergoing first-time ablation for VAs originated from distal great cardiac vein (DGCV), aortic sinus cusps (ASCs), or pulmonary sinus cusps (PSCs) were enrolled in present study. Local intracardiac bipolar recordings on 243 successful sites and 506 attempted but unsuccessful ablation sites were analysed. Specific potentials in bi-EGMs on successful sites were more common compared with unsuccessful sites (76.95%, 187/243 vs. 25.49%, 129/506, P < 0.05). A total of 60.00% (81/135) patients in ASCs group presented a presystolic short-duration fractionated potential, higher than 23.21% (13/56) in DGCV and 23.08% (12/52) in PSCs (all P < 0.05); 44.23% (23/52) patients in PSC group showed a presystolic high-amplitude discrete potential, while 1.79% (1/56) in DGCV and 2.22% (3/135) in ASCs (all P < 0.05); 41.07% (23/56) patients in DGCV group showed bi-EGMs of presystolic long-duration multicomponent fractionated potential, which was significantly higher than 3.85% (2/52) in PSCs and 4.44%(6/135) in ASCs (all P < 0.05).
Conclusion
Distinctive morphology of bi-EGMs during VAs can be found in different regions of VOT, which probably due to changes in the arrangements of myocardial sleeves. Correct identification and better understanding of the distinctive features of these bi-EGMs with regards to the anatomic location was important, the presence of specific potentials may add help in successful ablation.

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

Europace: 31 Aug 2020; 22:1367-1375
Li J, Lin W, Zheng C, Zhang C, Yu J, Lin J
Europace: 31 Aug 2020; 22:1367-1375 | PMID: 32449935
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Impact:
Abstract

Restoration of sinus rhythm by pulmonary vein isolation improves heart failure with preserved ejection fraction in atrial fibrillation patients.

Rattka M, Pott A, Kühberger A, Weinmann K, ... Rottbauer W, Dahme T
Aims
Atrial fibrillation (AF) in patients suffering from heart failure with preserved ejection fraction (HFpEF) is associated with increased symptoms and higher morbidity and mortality. Effective treatment strategies for this patient population have not yet been established.
Methods and results
We analysed clinical outcomes and echocardiographic parameters of patients with AF and HFpEF who underwent pulmonary vein isolation (PVI). Out of 374 PVI patients, we identified 35 patients suffering from concomitant HFpEF. Freedom from atrial tachyarrhythmia (AT) after 1 year was 80%. Heart failure symptoms assessed by New York Heart Association class significantly improved from 2.7 ± 0.7 to 1.7 ± 0.9 (P < 0.001). We observed regression of diastolic dysfunction by echocardiography 12 months after the index procedure. Moreover, 15 patients (42.9%) experienced complete resolution of HFpEF after a single ablation procedure. Multivariate logistic regression revealed absence of AT recurrence as an independent predictor of recovery from HFpEF (hazard ratio 11.37, 95% confidence interval 1.70-75.84, P = 0.009). Furthermore, resolution of HFpEF by achieving freedom from AT recurrence by PVI, including multiple procedures, led to a significant reduction of hospitalizations.
Conclusion
Our results suggest that restoration of sinus rhythm by PVI in HFpEF patients with concomitant AF induces reverse remodelling, improvement of symptoms, resolution of HFpEF and subsequently decrease of hospitalizations. Randomized controlled trials are warranted to confirm our results.

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

Europace: 31 Aug 2020; 22:1328-1336
Rattka M, Pott A, Kühberger A, Weinmann K, ... Rottbauer W, Dahme T
Europace: 31 Aug 2020; 22:1328-1336 | PMID: 32449907
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Impact:
Abstract

Outcome of cardiac tamponades in interventional electrophysiology.

Fink T, Sciacca V, Feickert S, Metzner A, ... Kuck KH, Rillig A
Aims
The aim of this study was to analyse tamponades following electrophysiological procedures regarding frequency and mortality in a high-volume centre and to identify independent predictors for severe tamponades.
Methods and results
We performed a retrospective study on 34 982 consecutive patients undergoing diagnostic electrophysiological studies or catheter ablation of cardiac arrhythmias. The combined endpoint was defined as severe tamponade. Criteria for severe tamponade included surgical repair, repeat pericardiocentesis, cardiopulmonary resuscitation, intrahospital death or death during follow-up, and thrombo-embolic events or complications due to therapeutic management. Multivariate analysis was performed to identify independent predictors for severe tamponade. A total of 226 tamponades were identified. Overall frequency of tamponades was 0.6%. Procedures requiring epicardial approach had the highest rate of tamponades (9.4%). Twenty-nine patients with tamponade underwent surgery (12.8% of all tamponades and 21.4% of tamponades during epicardial procedures). Overall tamponade-related mortality was 0.03% (9 deaths). Fifty-six patients (24.8%) experienced severe tamponade. Independent risk factors for severe tamponades were endocardial ablation of ventricular tachycardia, epicardial approach, balloon device ablation, high aspiration volume during pericardiocentesis and structural heart disease.
Conclusion
The frequency of tamponades is strongly dependent on the type of procedure performed. Overall tamponade-related mortality was low but significantly higher in patients undergoing epicardial procedures. Surgical backup should be considered for patients undergoing complex ventricular tachycardia ablation and left atrial ablation procedures.

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

Europace: 31 Jul 2020; 22:1240-1251
Fink T, Sciacca V, Feickert S, Metzner A, ... Kuck KH, Rillig A
Europace: 31 Jul 2020; 22:1240-1251 | PMID: 32500141
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Impact:
Abstract

Oral caffeine intake amplifies the effect of isoproterenol in patients with frequent premature ventricular contractions.

Hasebe H, Yoshida K, Furuyashiki Y, Nogami A, Ieda M
Aims
Infrequent appearance and failed induction of premature ventricular contractions (PVCs) at catheter ablation make their localization difficult and are associated with a poor procedural outcome. This study aimed to assess the effect of preprocedural oral caffeine intake on induction of PVCs during catheter ablation.
Methods and results
Seventy patients (age: 54 ± 14 years, 37 men) undergoing catheter ablation for monofocal PVCs were randomized to receive oral caffeine (5 mg/kg) or placebo. Before ablation, PVC counts for 5 min were performed at baseline and during isoproterenol infusion and the isoproterenol washout period. PVC count fluctuation was defined as the difference between the highest and lowest 5-min count among the three-time periods. The 5-min PVC counts during baseline and isoproterenol infusion were equivalent between the groups. However, those during the isoproterenol washout period and PVC count fluctuation were significantly higher in the caffeine group than the control group (73.1 ± 73.2 vs. 38.9 ± 28.9 beats/5 min, P = 0.012 and 69.3 ± 61.3 vs. 37.7 ± 30.9 beats/5 min, P = 0.008, respectively). The procedure and ablation times were significantly shorter in the caffeine group than the control group (105.0 ± 23.4 vs. 136.9 ± 43.2 min, P < 0.01 and 219.1 ± 104.7 vs. 283.5 ± 136.0 sec, P < 0.01, respectively).
Conclusion 
Oral caffeine intake amplified the effect of isoproterenol infusion on PVC induction during catheter ablation. The combined use of oral caffeine intake and isoproterenol infusion can be an option to increase intraprocedural PVCs.

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

Europace: 31 Jul 2020; 22:1261-1269
Hasebe H, Yoshida K, Furuyashiki Y, Nogami A, Ieda M
Europace: 31 Jul 2020; 22:1261-1269 | PMID: 32500131
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Impact:
Abstract

Outcomes in patients with cardiac amyloidosis and implantable cardioverter-defibrillator.

Kim EJ, Holmes BB, Huang S, Lugo R, ... Michaud GF, John RM
Aims
Cardiac amyloidosis (CA) is associated with increased mortality due to arrhythmias, heart failure, and electromechanical dissociation. However, the role of an implantable cardioverter-defibrillator (ICD) remains unclear. We conducted case-control study to assess survival in CA patients with and without a primary prevention ICD and compared outcomes to an age, sex, and device implant year-matched non-CA group with primary prevention ICD.
Methods and results
There were 91 subjects with CA [mean age= 71.2 ± 10.2, female 22.0%, 49 AL with Mayo Stage 2.9 ± 1.0, 41 transthyretin amyloidosis (ATTR), 1 other] followed by Vanderbilt Amyloidosis centre. Patients with ICD (n = 23) were compared with those without (n = 68) and a non-amyloid group with ICD (n = 46). All subjects with ICD had implantation for primary prevention. Mean left ventricular ejection fraction was 36.2% ± 14.4% in CA with ICD, 41.0% ± 10.6% in CA without ICD, and 33.5% ± 14.4% in non-CA patients. Over 3.5 ± 3.1 years, 6 (26.1%) CA, and 12 (26.1%) non-CA subjects received ICD therapies (P = 0.71). Patients with CA had a significantly higher mortality (43.9% vs. 17.4%, P = 0.002) compared with the non-CA group. Mean time from device implantation to death was 21.8 months in AL and 22.8 months in ATTR patients. There was no significant difference in mortality between CA patients who did and did not receive an ICD (39.0% vs. 46.0%, P = 0.59).
Conclusions
Despite comparable event rates patients with CA had a significantly higher mortality and ICDs were not associated with longer survival. With the emergence of effective therapy for AL amyloidosis, further study of ICD is needed in this group.

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

Europace: 31 Jul 2020; 22:1216-1223
Kim EJ, Holmes BB, Huang S, Lugo R, ... Michaud GF, John RM
Europace: 31 Jul 2020; 22:1216-1223 | PMID: 32514579
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Impact:
Abstract

Identification of circumferential pulmonary vein isolation responders among patients with persistent atrial fibrillation: clinical value of the sequential low-dose ibutilide test.

He SN, Tian Y, Shi L, Wang YJ, ... Yang XC, Liu XP
Aims
Circumferential pulmonary vein isolation can be effective as sole treatment for persistent atrial fibrillation. However, identifying those patients who will respond to this therapy remains a challenge. We investigated the clinical value of the sequential low-dose ibutilide test for identifying patients with persistent atrial fibrillation in whom pulmonary vein isolation is effective as sole therapy.
Methods and results
In a prospective cohort of 180 consecutive patients with persistent atrial fibrillation, intravenous low-dose (0.004 mg/kg) ibutilide was administered 3 days before ablation and after the completion of circumferential pulmonary vein isolation. In patients in whom ibutilide did not terminate atrial fibrillation pre-procedurally, but successfully terminated it intraprocedurally, no further atrial substrate modification was performed. Pre-procedural low-dose ibutilide failed to terminate the arrhythmia in all patients with persistent atrial fibrillation, while pulmonary vein isolation ± low-dose ibutilide terminated persistent atrial fibrillation in 55 (30.6%) of them (PsAF group 1). The remaining 125 (69.4%) patients underwent electrogram-based ablation (PsAF Group 2). The control group comprised 379 consecutive patients with paroxysmal atrial fibrillation who underwent pulmonary vein isolation over the same period. At 24 months follow-up, 39 (70.9%) patients in PsAF Group 1 and 276 (72.8%) patients in the control group were free from atrial tachyarrhythmias (P = NS); the arrhythmia-free rates in both groups were higher than that in PsAF group 2 (58.4%, P = 0.005).
Conclusion
The sequential low-dose ibutilide test is a simple method for identifying patients with persistent atrial fibrillation in whom pulmonary vein isolation alone is an appropriate treatment strategy.

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

Europace: 31 Jul 2020; 22:1197-1205
He SN, Tian Y, Shi L, Wang YJ, ... Yang XC, Liu XP
Europace: 31 Jul 2020; 22:1197-1205 | PMID: 32514560
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Impact:
Abstract

Left bundle branch pacing improved heart function in a 10-year-old child after a 3-month follow-up.

Ji W, Chen X, Shen J, Zhu D, Chen Y, Li F
Aims
As a physiological pacing strategy, left bundle branch pacing (LBBP) were used to correct left bundle branch block (LBBB), however, there is no relevant report in children. We aimed to evaluate the feasibility of LBBP in children.
Methods and results
Left bundle branch pacing was performed in a 10-year-old girl with a second-degree atrioventricular and LBBB. Under the guide of fluoroscopy, the pacing lead was deeply screwed into the interventricular septum to gain right bundle branch block (RBBB) pattern of paced QRS. Selective LBBP was achieved with a typical RBBB pattern of paced morphology and a discrete component between stimulus and ventricular activation in intracardiac electrogram and reached the standard of the stimulus to left ventricular activation time of 56 ms. At a 3-month follow-up, the LBBP acquired the reduction of left ventricular size and enhancement of left ventricular ejection fraction.
Conclusion
The application of LBBP in a child was first achieved with inspiring preliminary results. The LBBP can be carried out in children by cautiousness under the premise of strict grasp of indications.

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

Europace: 31 Jul 2020; 22:1234-1239
Ji W, Chen X, Shen J, Zhu D, Chen Y, Li F
Europace: 31 Jul 2020; 22:1234-1239 | PMID: 32529257
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Impact:
Abstract

Prolonged left ventricular contraction duration in apical segments as a marker of arrhythmic risk in patients with long QT syndrome.

Borowiec K, Kowalski M, Kumor M, Duliban J, ... Hoffman P, Biernacka EK
Aims
Long QT syndrome (LQTS) is an inherited cardiac ion channelopathy predisposing to life-threatening ventricular arrhythmias and sudden cardiac death. The aim of this study was to investigate left ventricular mechanical abnormalities in LQTS patients and establish a potential role of strain as a marker of arrhythmic risk.
Methods and results
We included 47 patients with genetically confirmed LQTS (22 LQT1, 20 LQT2, 3 LQT3, and 2 SCN3B) and 25 healthy controls. A history of cardiac events was present in 30 LQTS subjects. Tissue Doppler and speckle tracking echocardiography were performed and contraction duration was measured by radial and longitudinal strain. The radial strain characteristic was subdivided into two planes - the basal and the apical. Left ventricular ejection fraction and global longitudinal strain were normal in LQTS patients. Mean contraction duration was longer in LQTS patients compared with controls in regard to basal radial strain (491 ± 57 vs. 437 ± 55 ms, P < 0.001), apical radial strain (450 ± 53 vs. 407 ± 53 ms, P = 0.002), and longitudinal strain (445 ± 34 vs. 423 ± 43 ms, P = 0.02). Moreover, contraction duration obtained from apical radial strain analysis was longer in symptomatic compared with asymptomatic LQTS mutation carriers (462 ± 49 vs. 429 ± 55 ms, P = 0.024), as well as in subject with mutations other than LQT1 considered to be at higher risk (468 ± 50 vs. 429 ± 49 ms, P = 0.01).
Conclusion
Myocardial contraction duration is prolonged for both radial and longitudinal directions in LQTS patients. Regional left ventricular function analysis may contribute to risk stratification. Apical radial deformation seems to select subjects at higher risk of arrhythmic events.

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

Europace: 31 Jul 2020; 22:1279-1286
Borowiec K, Kowalski M, Kumor M, Duliban J, ... Hoffman P, Biernacka EK
Europace: 31 Jul 2020; 22:1279-1286 | PMID: 32529202
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Abstract

Sex differences in atrial fibrillation ablation outcomes: insights from a large-scale multicentre registry.

Tanaka N, Inoue K, Kobori A, Kaitani K, ... Kimura T, Shizuta S
Aim
The impact of sex differences on the clinical outcomes of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) is controversial. We investigated the sex differences regarding the efficacy and clinical outcomes of RFCA of AF.
Methods and results
We conducted a large-scale, prospective, multicentre, observational study (Kansai Plus Atrial Fibrillation Registry). We enrolled 5010 consecutive patients who underwent an initial RFCA of AF at 26 centres (64 ± 10 years; non-paroxysmal AF, 35.7%). The median follow-up duration was 2.9 years. Female patients (n = 1369, 27.3%) were older (female vs. male, 68 ± 9 vs. 63 ± 11 years, P < 0.0001) with a lower prevalence of non-paroxysmal AF (27.1% vs. 38.9%, P < 0.0001). Fewer females experienced time-dependent pulmonary vein (PV) reconnections and more females received a non-PV foci ablation than males in the index RFCA. The 3-year cumulative incidence of AF recurrences in the multivariate analysis after single procedures was significantly higher in females than males (43.3% vs. 39.0%, log rank P = 0.0046). Females remained an independent predictor of AF recurrence (hazard ratio 1.24; 95% confidence interval 1.12-1.38, P < 0.0001). The AF recurrence rates after multiple procedures were also higher in females, but fewer females experienced PV reconnections during second sessions. More females experienced de novo pacemaker implantations during the long-term follow-up. Females were associated with a higher risk of heart failure hospitalizations and major bleeding after RFCA in the multivariate analysis.
Conclusions
Females experienced more frequent AF recurrences probably due to non-PV arrhythmogenicity and de novo pacemaker implantations than males during the long-term follow-up after RFCA of AF.

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

Europace: 31 Aug 2020; 22:1345-1357
Tanaka N, Inoue K, Kobori A, Kaitani K, ... Kimura T, Shizuta S
Europace: 31 Aug 2020; 22:1345-1357 | PMID: 32548641
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Abstract

Orthogonal P-wave morphology, conventional P-wave indices, and the risk of atrial fibrillation in the general population using data from the Finnish Hospital Discharge Register.

Eranti A, Carlson J, Kenttä T, Holmqvist F, ... Junttila MJ, Platonov PG
Aims
Identifying subjects at high and low risk of atrial fibrillation (AF) is of interest. This study aims to assess the risk of AF associated with electrocardiographic (ECG) markers linked to atrial fibrosis: P-wave prolongation, 3rd-degree interatrial block, P-terminal force in lead V1, and orthogonal P-wave morphology.
Methods and results
P-wave parameters were assessed in a representative Finnish population sample aged ≥30 years (n = 7217, 46.0% male, mean age 51.4 years). Subjects (n = 5489) with a readable ECG including the orthogonal leads, sinus rhythm, and a predefined orthogonal P-wave morphology type [positive in leads X and Y and either negative (Type 1) or ± biphasic (Type 2) in lead Z; Type 3 defined as positive in lead X and ± biphasic in lead Y], were followed 10 years from the baseline examinations (performed 1978-80). Subjects discharged with AF diagnosis after any-cause hospitalization (n = 124) were defined as having developed AF. Third-degree interatrial block was defined as P-wave ≥120 ms and the presence of ≥2 ± biphasic P waves in the inferior leads. Hazard ratios (HRs) and confidence intervals (CIs) were assessed with Cox models. Third-degree interatrial block (n = 103, HR 3.18, 95% CI 1.66-6.13; P = 0.001) and Type 3 morphology (n = 216, HR 3.01, 95% CI 1.66-5.45; P < 0.001) were independently associated with the risk of hospitalization with AF. Subjects with P-wave <110 ms and Type 1 morphology (n = 2074) were at low risk (HR 0.46, 95% CI 0.26-0.83; P = 0.006), compared to the rest of the subjects.
Conclusion
P-wave parameters associate with the risk of hospitalization with AF.

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

Europace: 31 Jul 2020; 22:1173-1181
Eranti A, Carlson J, Kenttä T, Holmqvist F, ... Junttila MJ, Platonov PG
Europace: 31 Jul 2020; 22:1173-1181 | PMID: 32556298
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Abstract

C-reactive protein after coronary artery bypass graft surgery and its relationship with postoperative atrial fibrillation.

Olesen OJ, Vinding NE, Østergaard L, Butt JH, ... Køber L, Fosbøl EL
Aims
Postoperative atrial fibrillation (POAF), a common complication following coronary artery bypass graft (CABG) surgery, is associated with increased morbidity and mortality. Inflammation may be an important factor for the pathogenesis of POAF, and increased preoperative levels of C-reactive protein (CRP) are associated with the development of POAF. However, the relationship between postoperative CRP and POAF is less well established.
Methods and results
Patients undergoing first-time isolated CABG surgery (1 January 2000-31 December 2016) were identified using the Eastern Danish Heart Surgery Database and nationwide administrative registries. Patients with no history of atrial fibrillation and with available CRP measurements from postoperative day (POD) 4 were included. The study population was divided into quartiles based on CRP. The association between CRP levels and the odds of developing POAF was investigated using multivariable logistic regression analysis. We included 6711 patients. The CRP intervals on POD 4 for the CRP groups (lowest to highest) were ≤90, >90 to ≤127, >127 to ≤175, and >175 mg/L, respectively. Patients in the highest CRP group were older and more often men compared with patients in the lowest CRP group [median age 67 years (P25-P75: 61-73) and 84.7% men vs. median age 64 years (P25-P75: 56-70) and 77.9% men]. In the lowest and highest CRP groups, 25% and 35% developed POAF, respectively. In adjusted analysis, the highest CRP group, compared with the lowest CRP group, was associated with greater odds of developing POAF (odds ratio 1.31; 95% confidence interval 1.12-1.54).
Conclusion
Increased postoperative CRP levels after CABG surgery was associated with the development of POAF.

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

Europace: 31 Jul 2020; 22:1182-1188
Olesen OJ, Vinding NE, Østergaard L, Butt JH, ... Køber L, Fosbøl EL
Europace: 31 Jul 2020; 22:1182-1188 | PMID: 32623472
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Abstract

Temporal patterns and short-term progression of paroxysmal atrial fibrillation: data from RACE V.

De With RR, Erküner Ö, Rienstra M, Nguyen BO, ... Van Gelder IC,
Aims
Atrial fibrillation (AF) often starts as a paroxysmal self-terminating arrhythmia. Limited information is available on AF patterns and episode duration of paroxysmal AF. In paroxysmal AF patients, we longitudinally studied the temporal AF patterns, the association with clinical characteristics, and prevalence of AF progression.
Methods and results
In this interim analysis of the Reappraisal of AF: Interaction Between HyperCoagulability, Electrical Remodelling, and Vascular Destabilisation in the Progression of AF (RACE V) registry, 202 patients with paroxysmal AF were followed with continuous rhythm monitoring (implantable loop recorder or pacemaker) for 6 months. Mean age was 64 ± 9 years, 42% were women. Atrial fibrillation history was 2.1 (0.5-4.4) years, CHA2DS2-VASc 1.9 ± 1.3, 101 (50%) had hypertension, 69 (34%) heart failure. One-third had no AF during follow-up. Patients with long episodes (>12 hours) were often men with more comorbidities (heart failure, coronary artery disease, higher left ventricular mass). Patients with higher AF burden (>2.5%) were older with more comorbidities (worse renal function, higher calcium score, thicker intima media thickness). In 179 (89%) patients, 1-year rhythm follow-up was available. On a quarterly basis, average daily AF burden increased from 3.2% to 3.8%, 5.2%, and 6.1%. Compared to the first 6 months, 111 (62%) patients remained stable during the second 6 months, 39 (22%) showed progression to longer AF episodes, 8 (3%) developed persistent AF, and 29 (16%) patients showed AF regression.
Conclusions
In paroxysmal AF, temporal patterns differ suggesting that paroxysmal AF is not one entity. Atrial fibrillation burden is low and determined by number of comorbidities. Atrial fibrillation progression occurred in a substantial number.
Trial registration number
Clinicaltrials.gov identifier NCT02726698.

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

Europace: 31 Jul 2020; 22:1162-1172
De With RR, Erküner Ö, Rienstra M, Nguyen BO, ... Van Gelder IC,
Europace: 31 Jul 2020; 22:1162-1172 | PMID: 32642768
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Abstract

Complementary effectiveness of carotid sinus massage and tilt testing for the diagnosis of reflex syncope in patients older than 40 years: a cohort study.

Brignole M, Kessisoglu F, Croci F, Solano A, ... Casini N, Ungar A
Aims
Indications, methodology, and diagnostic criteria for carotid sinus massage (CSM) and tilt testing (TT) have been standardized by the 2018 Guidelines on Syncope of the European Society of Cardiology. Aim of this study was to assess their effectiveness in a large cohort which reflects the performance under \'real-world\' conditions.
Methods and results
We analysed all patients who had undergone CSM and TT in the years 2003-2019 for suspected reflex syncope. Carotid sinus massage was performed according to the \'Method of Symptoms\'. Tilt testing was performed according to the \'Italian protocol\' which consists of a passive phase followed by a sublingual nitroglycerine phase. For both tests, positive test was defined as reproduction of spontaneous symptoms in the presence of bradycardia and/or hypotension. Among 3293 patients (mean age 73 ± 12 years, 48% males), 2019 (61%) had at least one test positive. A bradycardic phenotype was found in 420 patients (13%); of these, 60% were identified by CSM, 37% by TT, and 3% had both test positive. A hypotensive phenotype was found in 1733 patients (53%); of these, 98% were identified by TT and 2% had both TT and CSM positive.
Conclusion
The overall diagnostic yield of the tests in patients >40-year-old with suspected reflex syncope was 61%. Both CSM and TT are useful for identifying those patients with a bradycardic phenotype, whereas CSM has a limited value for identifying the hypotensive phenotype. Since the overlap of responses between tests is minimal, both CSM and TT should be performed in every patient over 40 years receiving investigation for unexplained but possible reflex syncope.

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

Europace: 19 Oct 2020; epub ahead of print
Brignole M, Kessisoglu F, Croci F, Solano A, ... Casini N, Ungar A
Europace: 19 Oct 2020; epub ahead of print | PMID: 33078193
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