<div><h4>Colchicine usage for prevention of post atrial fibrillation ablation pericarditis in patients undergoing high-power short-duration ablation.</h4><i>Iqbal AM, Li KY, Gautam S</i><br /><b>Introduction</b><br />Radiofrequency ablation (RFA) for atrial fibrillation (AF) has been associated with variable incidence (0.88%-10%) of pericarditis manifested as chest pain, possibly more prevalent with the advent of high-power short-duration (HPSD) ablation. This has led to the widespread use of colchicine in preventative protocols for postablation pericarditis. However, the efficacy of preventative colchicine has not been validated yet.<br /><b>Objective</b><br />To evaluate the efficacy of a routine postoperative colchicine regimen (0.6 mg twice a day for 14 days post-AF ablation) for prevention of postablation pericarditis in patients undergoing HPSD ablation.<br /><b>Method</b><br />We retrospectively evaluated consecutive single-operator HPSD AF ablation procedures at our institution from June 2019 to July 2022. A colchicine protocol was introduced in June 2021 for the prevention of postablation pericarditis. All ablations were performed with 50 watts. Patients were divided into colchicine and noncolchicine groups. We recorded incidence of postablation chest pain, emergency room (ER) visit for chest pain, pericardial effusion, pericardiocentesis, any ER visit, hospitalization, AF recurrence, and cardioversion for AF within the first 30 days following ablation. We also recorded colchicine-related side effects and medication compliance.<br /><b>Results</b><br />Two hundred and ninety-four consecutive HPSD AF ablation patients were screened for the study. After implementing the prespecified exclusion criteria, a total of 205 patients were included in the final analysis, yielding 101 patients in the colchicine group and 104 patients in the noncolchicine group. Both groups were well-matched for demographic and procedural parameters. There was no significant difference in postablation chest pain (9.9% vs. 8.6%, p = .7), pericardial effusion (2.9% vs. 0.9%, p = .1), ER visits (11.9% vs. 12.5%, p = .2), 30-day hospitalization for AF recurrence (0.9% vs. 0.96%, p = .3), and 30-day need for cardioversion for AF (3.9% vs. 5.7%, p = .2). patients had severe colchicine-related diarrhea, out of which 12 discontinued it prematurely. There were no major procedural complications in either group.<br /><b>Conclusion</b><br />In this single-operator retrospective analysis, prophylactic colchicine was not associated with significant reduction in the incidence of postablation chest pain, pericarditis, 30 day hospitalization, ER visits, or AF recurrence or need of cardioversion within first 30 days after HPSD ablation for AF. However, its usage was associated with significant diarrhea. This study concludes no additional advantage of prophylactic use of colchicine after HPSD AF ablation.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 26 May 2023; epub ahead of print</small></div>

<div><h4>Electrophysiological study prior to planned pulmonary valve replacement in patients with repaired tetralogy of Fallot.</h4><i>Bouyer B, Jalal Z, Daniel Ramirez F, Derval N, ... Thambo JB, Sacher F</i><br /><b>Aim</b><br />Ventricular arrhythmias (VAs) are the most common cause of death in patients with repaired Tetralogy of Fallot (rTOF). However, risk stratifying remains challenging. We examined outcomes following programmed ventricular stimulation (PVS) with or without subsequent ablation in patients with rTOF planned for pulmonary valve replacement (PVR).<br /><b>Methods</b><br />We included all consecutive patients with rTOF referred to our institution from 2010 to 2018 aged ≥18 years for PVR. Right ventricular (RV) voltage maps were acquired and PVS was performed from two different sites at baseline, and if non-inducible under isoproterenol. Catheter and/or surgical ablation was performed when patients were inducible or when slow conduction was present in anatomical isthmuses (AIs). Postablation PVS was undertaken to guide implantable cardioverter-defibrillator (ICD) implantation.<br /><b>Results</b><br />Seventy-seven patients (36.2 ± 14.3 years old, 71% male) were included. Eighteen were inducible. In 28 patients (17 inducible, 11 non-inducible but with slow conduction) ablation was performed. Five had catheter ablation, surgical cryoablation in 9, both techniques in 14. ICDs were implanted in five patients. During a follow-up of 74 ± 40 months, no sudden cardiac death occurred. Three patients experienced sustained VAs, all were inducible during the initial EP study. Two of them had an ICD (low ejection fraction for one and important risk factor for arrhythmia for the second). No VAs were reported in the non-inducible group (p < .001).<br /><b>Conclusion</b><br />Preoperative EPS can help identifying patients with rTOF at risk for VAs, providing an opportunity for targeted ablation and may improve decision-making regarding ICD implantation.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 26 May 2023; epub ahead of print</small></div>

<div><h4>Very late-onset atrial lead perforation leading to pneumopericardium.</h4><i>Enokizono K, Kamakura T, Kotoku A, Nakata J, Matama H, Kusano K</i><br /><b>Background</b><br />Atrial lead perforation may lead to pneumopericardium or pneumothorax within a few days of device implantation.<br /><b>Methods and results</b><br />We report a case of atrial lead perforation 6 years after cardiac resynchronization therapy implantation, which resulted in pneumopericardium and pneumothorax.<br /><b>Conclusion</b><br />Although pneumopericardium caused by atrial lead perforation can spontaneously resolve with conservative treatment, as it did in this case, treatment should be decided based on the patient\'s general condition and lead performance.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 24 May 2023; epub ahead of print</small></div>

<div><h4>Right atrial collision time (RACT): A novel marker of propensity for typical atrial flutter.</h4><i>Ryckman N, Crinion D, Enriquez A, Bakker D, ... Simpson C, Redfearn DP</i><br /><b>Introduction</b><br />The risk of typical atrial flutter (AFL) is increased proportionately to right atrial (RA) size or right atrial scarring that results in reduced conduction velocity. These characteristics result in propagation of a flutter wave by ensuring the macro re-entrant wave front does not meet its refractory tail. The time taken to traverse the circuit would take account of both of these characteristics and may provide a novel marker of propensity to develop AFL. Our goal was to investigate right atrial collision time (RACT) as a marker of existing typical AFL.<br /><b>Methods</b><br />This single-centre, prospective study recruited consecutive typical AFL ablation patients that were in sinus rhythm. Controls were consecutive electrophysiology study patients >18 years of age. While pacing the coronary sinus (CS) ostium at 600 ms, a local activation time map was created to locate the latest collision point on the anterolateral right atrial wall. This RACT is a measure of conduction velocity and distance from CS to a collision point on the lateral right atrial wall.<br /><b>Results</b><br />Ninety-eight patients were included in the analysis, 41 with atrial flutter and 57 controls. Patients with atrial flutter were older, 64.7 ± 9.7 versus 52.4 ± 16.8 years (<.001), and more often male (34/41 vs. 31/57 [.003]). The AFL group mean RACT (132.6 ± 17.3 ms) was significantly longer than that of controls (99.1 ± 11.6 ms) (p < .001). A RACT cut-off of 115.5 ms had a sensitivity and specificity of 92.7% and 93.0%, respectively for diagnosis of atrial flutter. A ROC curve indicated an AUC of 0.96 (95% CI: 0.93-1.0, p < .01).<br /><b>Conclusion</b><br />RACT is a novel and promising marker of propensity for typical AFL. This data will inform larger prospective studies.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 24 May 2023; epub ahead of print</small></div>

<div><h4>Adverse events associated with Aveir VR leadless pacemaker: A Food and Drug Administration MAUDE database study.</h4><i>Garg J, Shah K, Bhardwaj R, Contractor T, ... Turagam MK, Lakkireddy D</i><br /><b>Background</b><br />Leadless pacemaker (LP) offers an innovative approach for treating bradyarrhythmia, thus avoiding pacemaker pocket and lead-related complications. The Food and Drug Administration (FDA) has recently approved the Aveir™ leadless pacing system (screw-in type LP).<br /><b>Methods</b><br />We queried the FDA MAUDE database to study the safety profile and assess the types of complications with this relatively novel device technology. A MAUDE database search was conducted on January 20, 2023, for reports received post-FDA approval to capture all adverse events.<br /><b>Results</b><br />A total of 98 medical device report were reported for Aveir™ LP. After excluding duplicate, programmer-related, or introducer-sheath-related entries (n = 34), 64 entries were included. The most commonly encountered problem was high threshold/noncapture (28.1%, 18 events), followed by stretched helix (17.2%, 11 events) and device dislodgement (15.6%, ten events-5 intraprocedural, while 5 in the postoperative Day 1). Other reported events included high impedance (14.1%, nine events), sensing issues (12.5%, eight events), bent/broken helix (7.8%, five events), premature separation (4.7%, three events), interrogation problem (3.1%, two events), low impedance (3.1%, two events), premature battery depletion (1.6%, one event) and inadvertent MRI mode switch (1.6%, one event) and miscellaneous (15.6%, n = 10). There were eight serious patient injury events-pericardial effusion requiring pericardiocentesis (7.8%, five events) due to cardiac perforation that resulted in two deaths (3.1%) followed by sustained ventricular arrhythmias (4.6%, n = 3).<br /><b>Conclusion</b><br />In our study assessing the real-world safety profile of the Aveir™ LP, serious adverse events have been reported-life-threatening ventricular arrhythmias, pericardial effusion, device explantation/reimplantation, and death.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 20 May 2023; epub ahead of print</small></div>

<div><h4>Sotalol in neonates for arrythmias: Dosing, safety, and efficacy.</h4><i>Kiskaddon AL, Decker J</i><br /><b>Introduction</b><br />Various agents may be utilized to manage supraventricular tachycardia (SVT) in neonates and infants. Recently, sotalol has piqued interest given its reported success in managing neonates and infants with SVTs, especially with the intravenous formulation. While the manufacturer recommends using an age-related nomogram in neonates and young infants to guide doses, clinical reports describe various dosing based on weight (mg/kg) or on body surface area (BSA) in mg/m<sup>2</sup> . Given the reported variation in clinical practice with regard to dosing in neonates, there is a gap in the literature and translation into clinical practice regarding applicability of the nomogram into clinical practice. The purpose of this study was to describe sotalol doses based on body weight and BSA in neonates for SVT.<br /><b>Methods</b><br />This is a single center retrospective study evaluating effective sotalol dosing from January 2011 and June 2021 (inclusive). Neonates who received intravenous (IV) or oral (PO) sotalol for SVT were eligible for inclusion. The primary outcome was to describe sotalol doses based on body weight and BSA. Secondary outcomes include comparison of doses to the manufacturer nomogram, description of dose titrations, reported adverse outcomes, and change in therapy. Two-sided Wilcoxon signed-rank tests were used to determine statistically significant differences.<br /><b>Results</b><br />Thirty-one eligible patients were included in this study. The median (range) age and weight were 16.5 (1-28) days and 3.2 (1.8-4.9) kg, respectively. The median initial dose was 7.3 (1.9-10.8) mg/kg or 114.3 (30.9-166.7) mg/m<sup>2</sup> /day. Fourteen (45.2%) of patients required a dose increase for SVT control. The median dose required for rhythm control was 8.5 (2-14.8) mg/kg/day or 120.7 (30.9-225) mg/m<sup>2</sup> /day. Of note, the median recommended dose per manufacturer nomogram for our patients would have been 51.3 (16.2-73.8) mg/m<sup>2</sup> /day, which is significantly lower than both the initial dose (p < .001) and final doses (p < .001) utilized in our study. A total of 7 (22.9%) patients were uncontrolled on sotalol monotherapy using our dosing regimen. Two patients (6.5%) had reports of hypotension and one patient (3.3%) had a report of bradycardia requiring discontinuation of therapy. The average change in baseline QTC following sotalol initiation was 6.8%. Twenty-seven (87.1%), 3 (9.7%), 1 (3.3%) experienced prolongation, no change, or a decrease in QTc, respectively.<br /><b>Conclusions</b><br />This study demonstrates that a sotalol strategy significantly higher than the manufacture dose recommendations are required for rhythm control in neonates with SVT. There were few adverse events reported with this dosing. Further prospective studies would be advantageous to confirm these findings.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 20 May 2023; epub ahead of print</small></div>

<div><h4>Epicardial mapping and ablation of biatrial macroreentrant tachycardia via Bachmann\'s bundle.</h4><i>Yorgun H, Çöteli C, Kılıç GS, Ateş AH, Aytemir K</i><br /><b>Introduction</b><br />Recent reports highlighted the role of epicardial connections in the development of biatrial tachycardia circuits.<br /><b>Methods</b><br />We reported a case of 60-year-old female patient who was admitted with recurrent atrial tachycardia (AT) after endocardial pulmonary vein isolation and anterior mitral line formation.<br /><b>Results</b><br />Epicardial activation map demonstrated fragmented continuous potentials at the Bachmann\'s bundle region with good entrainment response. Epicardial radiofrequency ablation terminated AT with complete block in the anterior mitral line.<br /><b>Conclusions</b><br />This case corroborates the data relevant to the role of interatrial connections-specifically Bachmann\'s bundle-in biatrial macroreentrant ATs and demonstrates that epicardial mapping is an effective method to identify the entire reentrant circuit.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 20 May 2023; epub ahead of print</small></div>

<div><h4>Incidence of ventricular arrhythmias related to COVID infection and vaccination in patients with Brugada syndrome: Insights from a large Italian multicenter registry based on continuous rhythm monitoring.</h4><i>Casella M, Conti S, Compagnucci P, Ribatti V, ... Russo AD, Patti G</i><br /><b>Introduction</b><br />Brugada syndrome (BrS) has a dynamic ECG pattern that might be revealed by certain conditions such as fever. We evaluated the incidence and management of ventricular arrhythmias (VAs) related to COVID-19 infection and vaccination among BrS patients carriers of an implantable loop recorder (ILR) or implantable cardioverter-defibrillator (ICD) and followed by remote monitoring.<br /><b>Methods</b><br />This was a multicenter retrospective study. Patients were carriers of devices with remote monitoring follow-up. We recorded VAs 6 months before COVID-19 infection or vaccination, during infection, at each vaccination, and up to 6-month post-COVID-19 or 1 month after the last vaccination. In ICD carriers, we documented any device intervention.<br /><b>Results</b><br />We included 326 patients, 202 with an ICD and 124 with an ILR. One hundred and nine patients (33.4%) had COVID-19, 55% of whom developed fever. Hospitalization rate due to COVID-19 infection was 2.76%. After infection, we recorded only two ventricular tachycardias (VTs). After the first, second, and third vaccines, the incidence of non-sustained ventricular tachycardia (NSVT) was 1.5%, 2%, and 1%, respectively. The incidence of VT was 1% after the second dose. Six-month post-COVID-19 healing or 1 month after the last vaccine, we documented NSVT in 3.4%, VT in 0.5%, and ventricular fibrillation in 0.5% of patients. Overall, one patient received anti-tachycardia pacing and one a shock. ILR carriers had no VAs. No differences were found in VT before and after infection and before and after each vaccination.<br /><b>Conclusions</b><br />From this large multicenter study conducted in BrS patients, followed by remote monitoring, the overall incidence of sustained VAs after COVID-19 infection and vaccination is relatively low.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 17 May 2023; epub ahead of print</small></div>

<div><h4>Percutaneous epicardial pacing in infants using direct visualization: A feasibility animal study.</h4><i>Kumthekar RN, Opfermann JD, Mass P, Contento JM, Berul CI</i><br /><b>Background</b><br />Pacemaker implantation in infants and small children is limited to epicardial lead placement via open chest surgery. We propose a minimally invasive solution using a novel percutaneous access kit.<br /><b>Objective</b><br />To evaluate the acute safety and feasibility of a novel percutaneous pericardial access tool kit to implant pacemaker leads on the epicardium under direct visualization.<br /><b>Methods</b><br />A custom sheath with optical fiber lining the inside wall was built to provide intrathoracic illumination. A Veress needle inside the illumination sheath was inserted through a skin nick just to the left of the xiphoid process and angled toward the thorax. A needle containing a fiberscope within the lumen was inserted through the sheath and used to access the pericardium under direct visualization. A custom dilator and peel-away sheath with pre-tunneled fiberscope was passed over a guidewire into the pericardial space via modified Seldinger technique. A side-biting multipolar pacemaker lead was inserted through the sheath and affixed against the epicardium.<br /><b>Results</b><br />Six piglets (weight 3.7-4.0 kg) had successful lead implantation. The pericardial space could be visualized and entered in all animals. Median time from skin nick to sheath access of the pericardium was 9.5 (interquartile range [IQR] 8-11) min. Median total procedure time was 16 (IQR 14-19) min. Median R wave sensing was 5.4 (IQR 4.0-7.3) mV. Median capture threshold was 2.1 (IQR 1.7-2.4) V at 0.4 ms and 1.3 (IQR 1.2-2.0) V at 1.0 ms. There were no complications.<br /><b>Conclusion</b><br />Percutaneous epicardial lead implantation under direct visualization was successful in six piglets of neonatal size and weight with clinically acceptable acute pacing parameters.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 12 May 2023; epub ahead of print</small></div>

<div><h4>Optimization of the atrioventricular delay in conduction system pacing.</h4><i>Coluccia G, Dell\'Era G, Ghiglieno C, De Vecchi F, ... Accogli M, Palmisano P</i><br /><b>Introduction</b><br />In patients receiving conduction system pacing (CSP), it is not well established how to program the sensed atrioventricular delay (sAVD), with respect to the type of capture obtained (selective, nonselective His-bundle [HB] capture or left bundle branch [LBB] capture). The aim of this study was to acutely assess the effectiveness of an electrophysiology (EP)-guided method for sAVD optimization by comparing it with the echocardiogram-guided optimization.<br /><b>Methods and results</b><br />Consecutive patients undergoing HB or LBB pacing were enrolled. The EP-guided sAVD was defined as the sAVD leading to a PR interval of 150 ms on surface electrocardiogram (ECG). In HB pacing patients, EP-guided sAVD was obtained subtracting the time from the onset of the P wave on ECG to the local atrial electrogram (EGM) recorded by the atrial lead (right atrial sensing latency, RASL) and the His-ventricular interval from 150 ms; in LBB pacing patients, subtracting RASL from 150 ms. Transmitral flow assessment by pulsed wave Doppler was used to find the echo-optimized sAVD by a modified iterative method. The discordance between the EP-guided and the echo-optimized sAVD was recorded.<br /><b>Results</b><br />Seventy-one patients were enrolled: 12 with selective, 32 nonselective HB capture, and 27 LBB capture. Overall, the rate of concordance between the EP-guided and the echo-optimized sAVD was 71.8%, with no significant differences between the three groups.<br /><b>Conclusion</b><br />In CSP patients, an optimal sAVD can be programmed, in more than 70% of cases, considering only simple EGM intervals to obtain a physiological PR interval on surface ECG.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 10 May 2023; epub ahead of print</small></div>

<div><h4>Anatomical location of leadless pacemaker and the risk of pacing-induced cardiomyopathy.</h4><i>Shantha G, Brock J, Singleton M, Kozak P, ... Whalen P, Bhave PD</i><br /><b>Background</b><br />It is unclear if the location of implantation of the leadless pacemaker (LP) makes a difference in the incidence of pacing-induced cardiomyopathy (PICM).<br /><b>Aim</b><br />The aim of this study was to compare the incidence of PICM based on the location of implantation of LP.<br /><b>Methods</b><br />A total of 358 consecutive patients [women: 171 (48%), mean age: 73 ± 15 years] with left ventricular ejection fraction (EF) > 50%, who received an LP (Micra) between January 2017 and June 2022, formed the study cohort. Micra-AV and Micra-VR were implanted in 122 (34%) and 236 (66%) patients, respectively. Fluoroscopically, the location of implantation of LP in the interventricular septum (IS) was divided into two equal halves (apex/apical septum [AS] and mid/high septum [HS]). During follow-up, PICM was defined as an EF drop of ≥10%.<br /><b>Results</b><br />LP was implanted in 109 (34%) and 249 (66%) patients at AS and HS locations, respectively. During a mean 18 ± 8 months follow-up, 28 patients (7.8%) developed PICM. Among the 249 patients with HS placement of LP, 10 (4%) developed PICM, whereas among the 109 patients with AS placement of LP, 18 (16.5%) developed PICM (p = .002). AS location was associated with a higher risk of PICM compared to HS locations (adjusted hazard ratio: 4.42, p < .001).<br /><b>Conclusion</b><br />AS location of LP was associated with a higher risk of PICM compared to HS placement. Larger randomized studies are needed to confirm our findings.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 10 May 2023; epub ahead of print</small></div>

<div><h4>Predictors and outcomes of tricuspid regurgitation improvement after radiofrequency catheter ablation for persistent atrial fibrillation.</h4><i>Ukita K, Egami Y, Nohara H, Kawanami S, ... Nishino M, Tanouchi J</i><br /><b>Introduction</b><br />Little has been reported on the predictors and outcomes of improvement of tricuspid regurgitation (TR) after radiofrequency catheter ablation (RFCA) for persistent atrial fibrillation (AF).<br /><b>Methods</b><br />We enrolled 141 patients with persistent AF and moderate or severe TR assessed by transthoracic echocardiography (TTE) who underwent an initial RFCA between February 2015 and August 2021. These patients underwent follow-up TTE at 12 months after the RFCA, and were categorized into two groups based on the improvement (defined as at least one-grade improvement of TR) and non-improvement of TR: IM group and Non-IM group, respectively. We compared the patient characteristics, ablation procedures, and recurrences after the RFCA between the two groups. In addition, we examined the major event (defined as admission for heart failure or all-cause death) more than 12 months after the RFCA.<br /><b>Results</b><br />IM group consisted of 90 patients (64%). A multivariate analysis revealed that age <71 years old and absence of late recurrence (LR, defined as recurrence of atrial tachyarrhythmia between 3 and 12 months after the RFCA) were independently associated with the improvement of TR after the RFCA. Furthermore, IM group had the higher incidence of major event-free survival than Non-IM group.<br /><b>Conclusions</b><br />Relatively young age and absence of LR were good predictors of improvement of TR after the RFCA for persistent AF. In addition, the improvement of TR was related to better clinical outcomes.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 07 May 2023; epub ahead of print</small></div>

<div><h4>Risk of ventricular arrhythmias following implantable cardioverter-defibrillator generator change in patients with recovered ejection fraction: Implications for shared decision-making.</h4><i>Chang DD, Pantlin PG, Benn FA, Ryan Gullatt T, ... Velasco-Gonzalez C, Morin DP</i><br /><b>Introduction</b><br />Guidelines indicate primary-prevention implantable cardioverter-defibrillators (ICDs) for most patients with left ventricular ejection fraction (LVEF) ≤ 35%. Some patients\' LVEFs improve during the life of their first ICD. In patients with recovered LVEF who never received appropriate ICD therapy, the utility of generator replacement upon battery depletion remains unclear. Here, we evaluate ICD therapy based on LVEF at the time of generator change, to educate shared decision-making regarding whether to replace the depleted ICD.<br /><b>Methods</b><br />We followed patients with a primary-prevention ICD who underwent generator change. Patients who received appropriate ICD therapy for ventricular tachycardia or ventricular fibrillation (VT/VF) before generator change were excluded. The primary endpoint was appropriate ICD therapy, adjusted for the competing risk of death.<br /><b>Results</b><br />Among 951 generator changes, 423 met inclusion criteria. During 3.4 ± 2.2 years follow-up, 78 (18%) received appropriate therapy for VT/VF. Compared to patients with recovered LVEF > 35% (n = 161 [38%]), those with LVEF ≤ 35% (n = 262 [62%]) were more likely to require ICD therapy (p = .002; Fine-Gray adjusted 5-year event rates: 12.7% vs. 25.0%). Receiver operating characteristic analysis revealed the optimal LVEF cutoff for VT/VF prediction to be 45%, the use of which further improved risk stratification (p < .001), with Fine-Gray adjusted 5-year rates 6.2% versus 25.1%.<br /><b>Conclusion</b><br />Following ICD generator change, patients with primary-prevention ICDs and recovered LVEF have significantly lower risk of subsequent ventricular arrhythmias compared to those with persistent LVEF depression. Risk stratification at LVEF 45% offers significant additional negative predictive value over a 35% cutoff, without a significant loss in sensitivity. These data may be useful during shared decision-making at the time of ICD generator battery depletion.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 05 May 2023; epub ahead of print</small></div>

<div><h4>Ventricular pacing burden in patients with left bundle branch block after transcatheter aortic valve replacement therapy.</h4><i>Serban T, Knecht S, du Lavallaz JDF, Nestelberger T, ... Kühne M, Badertscher P</i><br /><b>Introduction</b><br />Electrophysiological testing has been proposed in the latest European Society of Cardiology (ESC) guidelines for cardiac pacing to identify left bundle branch block (LBBB) patients with infrahisian conduction delay (IHCD) after transcatheter aortic valve replacement (TAVR). While in general IHCD is defined by a His-ventricular (HV) interval of >55 ms, a cut-off of ≥70 ms to trigger pacemaker (PM) implantation has been proposed in the latest ESC guidelines. The ventricular pacing (VP) burden during follow-up in such patients is largely unknown. As such, we aimed to assess the VP burden during follow-up of patients receiving PM therapy for LBBB after TAVR based on an HV interval > 55 ms and ≥70 ms.<br /><b>Methods</b><br />All patients with new-onset or pre-existing LBBB after undergoing TAVR at a tertiary referral center underwent EP testing the day after TAVR. In patients with a prolonged HV interval (>55 ms), PM implantation was performed by a trained electrophysiologist in a standardized fashion. All devices were programmed to avoid unnecessary VP by specific algorithms (e.g., AAI-DDD).<br /><b>Results</b><br />701 patients underwent TAVR at the University Hospital of Basel. One hundred seventy-seven patients presented with new-onset or pre-existing LBBB the day following TAVR and underwent EP testing. An HV interval > 55 ms was found in 58 patients (33%) and an HV interval ≥ 70 ms in 21 patients (12%). 51 patients (mean age 84 ± 6.2 years, 45% women) agreed to receive a PM, out of which 20 (39%) patients had an HV Interval over 70 ms. Atrial fibrillation was present in 53% of the patients. A dual chamber PM was implanted in 39 (77%), and a single chamber PC in 12 (23%) patients, respectively. Median follow-up was 21 months. The median VP burden overall was 3%. The median VP burden was not significantly different between patients with an HV ≥ 70 ms (6.5 [0.8-52]) and those with an HV between 55 and 69 ms (2 [0-17], p = .23). 31% of patients demonstrated a VP burden < 1%, 27% 1%-5% and 41% > 5%. The median HV intervals in patients with VP burdens < 1%, 1%-5% and >5% were 66 (IQR 62-70) ms, 66 (IQR 63-74) ms and 68 (IQR 60-72) ms, respectively, p = .52. When only assessing patients with an HV interval 55-69 ms, 36% demonstrated a VP burden of <1%, 29% of 1%-5% and 35% of >5%. In patients with an HV Interval ≥ 70 ms, 25% demonstrated a VP burden < 1%, 25% of 1%-5% and 50% of >5% %, p = .64 (Figure).<br /><b>Conclusion</b><br />In patients with LBBB after TAVR and IHCD defined by an HV interval > 55 ms, VP burden is relevant in a non-negligible amount of patients during follow-up. Further studies are warranted to define the optimal cut-off value for the HV interval or to develop risk models incorporating HV measurements and other risk factors to trigger PM implantation in patients with LBBB after TAVR.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 05 May 2023; epub ahead of print</small></div>

<div><h4>Development of a carpark cardiac implantable electronic device clinic to improve time efficiency and patient satisfaction in the context of restrictions imposed by the COVID-19 pandemic.</h4><i>Enayati A, McCormack C, Mckenna J, Chye D, ... Lim HS, Teh AW</i><br /><b>Introduction</b><br />We evaluated time efficiency and patient satisfaction of a \"car park clinic\" (CPC) compared to traditional face-to-face (F2F) during the COVID-19 pandemic.<br /><b>Methods</b><br />Consecutive patients attending CPC between September 2020 and November 2021 were surveyed. CPC time was recorded by staff. F2F time was reported by patients and administrative data.<br /><b>Results</b><br />A total of 591 patients attended the CPC. A total of 176 responses were collected for F2F clinic. Regarding satisfaction, 90% of CPC patients responded \"happy\" or \"very happy.\" 96% reported feeling \"safe\" or \"very safe.\" Patients spent significantly less time in CPC compared to F2F (17 ± 8 vs. 50 ± 24 min, p < .001).<br /><b>Conclusion</b><br />CPC had excellent patient satisfaction and superior time efficiency compared to F2F.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 05 May 2023; epub ahead of print</small></div>

<div><h4>Same-day discharge for left atrial appendage occlusion procedure: A systematic review and meta-analysis.</h4><i>Khan JA, Parmar M, Bhamare A, Agarwal S, ... Stavrakis S, Asad ZUA</i><br /><b>Introduction</b><br />Most patients undergoing a left atrial appendage occlusion (LAAO) procedure are admitted for overnight observation. A same-day discharge strategy offers the opportunity to improve resource utilization without compromising patient safety. We compared the patient safety outcomes and post-discharge complications between same-day discharge versus hospital admission (HA) (>1 day) in patients undergoing LAAO procedure.<br /><b>Methods</b><br />A systematic search of MEDLINE and Embase was conducted. Outcomes of interest included peri-procedural complications, re-admissions, discharge complications including major bleeding and vascular complications, ischemic stroke, all-cause mortality, and peri-device leak >5 mm. Mantel-Haenszel risk ratios (RRs) with 95% CIs were calculated.<br /><b>Results</b><br />A total of seven observational studies met the inclusion criteria. There was no statistically significant difference between same-day discharge versus HA regarding readmission (RR: 0.61; 95% confidence interval [CI]: [0.29-1.31]; p = .21), ischemic stroke after discharge (RR: 1.16; 95% CI: [0.49-2.73]), peri-device leak >5 mm (RR: 1.27; 95% CI: [0.42-3.85], and all-cause mortality (RR: 0.60; 95% CI: [0.36-1.02]). The same-day discharge study group had significantly lower major bleeding or vascular complications (RR: 0.71; 95% CI: [0.54-0.94]).<br /><b>Conclusions</b><br />This meta-analysis of seven observational studies showed no significant difference in patient safety outcomes and post-discharge complications between same-day discharge versus HA. These findings provide a solid basis to perform a randomized control trial to eliminate any potential confounders.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 02 May 2023; epub ahead of print</small></div>

<div><h4>Advanced helix-fixation leadless cardiac pacemaker implantation techniques to improve success and reduce complications.</h4><i>Ip JE</i><br /><b>Introduction</b><br />Leadless cardiac pacemakers (LCPs) are becoming more commonly utilized because of their potential advantages (i.e., reduced short and long-term complications, improved patient comfort) and may be the preferred option for patients with venous access problems, high-risk for infection, previous lead fractures, or skin erosion. There are currently two types of LCP fixation mechanisms that have been FDA approved-Medtronic\'s Micra system has a tine-based fixation and Abbott\'s Aveir system has a helix-fixation design. This article highlights important tips and tricks for a successful implant of a helix-fixation LCP, particularly when difficulties are encountered, and provides precautions to avoid potential complications.<br /><b>Methods</b><br />Cases of single chamber Aveir LCP implantation were reviewed to highlight examples of procedural pitfalls and suggested methods to circumnavigate them.<br /><b>Results</b><br />There are unique procedural considerations regarding the Aveir LCP implant as well as challenges that that may be occasionally encountered. Techniques to address these-such as avoiding air embolism, maneuvering difficult entry into the right ventricle, handling complicated positioning/repositioning, evaluating proper fixation, and releasing difficult tethers-are illustrated in detail. Advice to reduce risks of perforation and to position optimally for potential retrieval and communication for dual chamber pacing are also described.<br /><b>Conclusions</b><br />The advanced teaching concepts described and emphasized in this article may help improve success and prevent procedural complications, especially when physicians are learning how implant these novel helix-fixation LCPs.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 01 May 2023; epub ahead of print</small></div>

<div><h4>Antitachycardia pacing at the His bundle is safer than conventional right ventricular antitachycardia pacing in a canine myocardial ischemic injury model.</h4><i>Hirahara AM, Khan MS, Gharbia OA, Lange M, ... Selzman CH, Dosdall DJ</i><br /><b>Introduction</b><br />Antitachycardia pacing (ATP) is used to terminate ventricular tachycardia (VT) by delivering rapid, low energy pacing to the right ventricle (RV). Unfortunately, ATP is not effective against all VT episodes and can result in adverse outcomes, such as VT acceleration and degeneration into ventricular fibrillation (VF). Improving ATP is therefore desirable. Our objective was to compare the efficacy and safety of ATP delivered at the His bundle to traditional ATP.<br /><b>Methods</b><br />Six dogs were anesthetized and pacing leads were implanted in the RV and His bundle. The left anterior descending artery was occluded for 2 h to create an ischemic injury. In a study 4-7 days later, a 128-electrode sock was placed snugly around the ventricles and VT was induced using rapid pacing. ATP was delivered from either the His bundle or RV lead, then attempted at the other location if unsuccessful. Success rates and instances of VT acceleration and degeneration into VF were calculated.<br /><b>Results</b><br />We induced 83 runs of VT and attempted ATP 128 times. RV ATP was successful in 36% of attempts; His ATP was successful in 38% of attempts. RV ATP resulted in significantly more adverse outcomes. RV and His ATP induced VT acceleration in 9% and 3% of trains, respectively, and induced degeneration into VF in 5% and 1% of trains, respectively.<br /><b>Conclusion</b><br />His bundle ATP is safer, but not significantly more effective, than RV ATP.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 01 May 2023; epub ahead of print</small></div>

<div><h4>Small solitary atrial fractionated electrogram zone as a novel ablation target for persistent atrial fibrillation.</h4><i>Yamaji H, Kawafuji S, Sano M, Higashiya S, ... Kamikawa S, Kusachi S</i><br /><b>Introduction</b><br />Various adjunctive approaches to pulmonary vein isolation (PVI) have been attempted for persistent atrial fibrillation (perAF) and longstanding persistent AF (ls-perAF). We aimed to identify the novel zones responsible for perpetuation of AF.<br /><b>Methods</b><br />To identify novel zones acting as a source of perAF and ls-perAF after PVI/re-PVI, we performed fractionation mapping in 258 consecutive patients with perAF (n = 207) and ls-perAF (n = 51) in whom PVI/re-PVI failed to restore sinus rhythm.<br /><b>Results</b><br />In 15 patients with perAF (5.8%: 15/258), fractionation mapping identified a small solitary zone (<1 cm<sup>2</sup> ) with high-frequency and irregular waves, showing fractionated electrograms (EGM). We defined this zone as the small solitary atrial fractionated EGM (SAFE) zone. The small SAFE zone was surrounded characteristically by a homogeneous area showing relatively organized activation with nonrapid and nonfractionated waves. Only one small SAFE zone was detected in each patient. This characteristic electrical phenomenon was observed stably during the procedure until ablation. AF duration, (defined as the duration between initial detection of AF and the current ablation) was longer in patients with the small SAFE zone than in those without (median, [25 and 75 percentiles]; 5.0 [3.5, 7.0] vs. 1.1 [1.0, 4.0] years, p = .0008). Longer AF cycle length was observed in patients with the small SAFE zone than in those without. The ablation of the small SAFE zone terminated AF in all 15 patients without any need for other ablations. AF/atrial tachycardia-free rate at follow-up was 93% (14/15) at 6 months, 87% (13/15) at 1 year, and 60% (9/15) at 2 years.<br /><b>Conclusions</b><br />Using fractionation mapping, this study identified a small SAFE zone surrounded characteristically by a homogeneous, relatively organized, low-excitability EGM lesion. The ablation of the small SAFE zone terminated AF in all patients, demonstrating it as a substrate for perpetuated AF. Our findings provide novel ablation targets in perAF patients with prolonged AF duration. Further studies to confirm the present results are warranted.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 27 Apr 2023; epub ahead of print</small></div>

<div><h4>Efficacy of intravenous magnesium for the management of non-post operative atrial fibrillation with rapid ventricular response: A systematic review and meta-analysis.</h4><i>Enayati A, Gin JH, Sajeev JK, Cooke JC, ... Teh AW, Nogic J</i><br /><b>Background</b><br />Intravenous magnesium (IV Mg), a commonly utilized therapeutic agent in the management of atrial fibrillation (AF) with rapid ventricular response, is thought to exert its influence via its effect on cellular automaticity and prolongation of atrial and atrioventricular nodal refractoriness thus reducing ventricular rate. We sought to undertake a systematic review and meta-analysis of the effectiveness of IV Mg versus placebo in addition to standard pharmacotherapy in the rate and rhythm control of AF in the nonpostoperative patient cohort given that randomized control trials (RCTs) have shown conflicting results.<br /><b>Methods</b><br />Randomized controlled trials comparing IV Mg versus placebo in addition to standard of care were identified via electronic database searches. Nine RCTs were returned with a total of 1048 patients. Primary efficacy endpoints were study-defined rate control and rhythm control/reversion to sinus rhythm. The secondary endpoint was patient experienced side effects.<br /><b>Results</b><br />Our analysis found IV Mg in addition to standard care was successful in achieving rate control (odd ratio [OR] 1.87, 95% confidence interval [CI] 1.13-3.11, p = .02) and rhythm control (OR 1.45, 95% CI 1.04-2.03, p = .03). Although not well reported among studies, there was no significant difference between groups regarding the likelihood of experiencing side effects.<br /><b>Conclusions</b><br />IV Mg, in addition to standard-of-care pharmacotherapy, increases the rates of successful rate and rhythm control in nonpostoperative patients with AF with rapid ventricular response and is well tolerated.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 26 Apr 2023; epub ahead of print</small></div>

<div><h4>Microelectrode voltage mapping for substrate assessment in catheter ablation of ventricular tachycardia: A dual-center experience.</h4><i>Dello Russo A, Compagnucci P, Bergonti M, Cipolletta L, ... Natale A, Casella M</i><br /><b>Introduction</b><br />The assessment of the ventricular myocardial substrate critically depends on the size of mapping electrodes, their orientation with respect to wavefront propagation, and interelectrode distance. We conducted a dual-center study to evaluate the impact of microelectrode mapping in patients undergoing catheter ablation (CA) of ventricular tachycardia (VT).<br /><b>Methods</b><br />We included 21 consecutive patients (median age, 68 [12], 95% male) with structural heart disease undergoing CA for electrical storm (n = 14) or recurrent VT (n = 7) using the QDOT Micro catheter and a multipolar catheter (PentaRay, n = 9). The associations of peak-to-peak maximum standard bipolar (BV<sub>c</sub> ) and minibipolar (PentaRay, BV<sub>p</sub> ) with microbipolar (BV<sub>μMax</sub> ) voltages were respectively tested in sinus rhythm with mixed effect models. Furthermore, we compared the features of standard bipolar (BE) and microbipolar (μBE) electrograms in sinus rhythm at sites of termination with radiofrequency energy.<br /><b>Results</b><br />BV<sub>μMax</sub> was moderately associated with both BV<sub>c</sub> (β = .85, p < .01) and BV<sub>p</sub> (β = .56, p < .01). BV<sub>μMax</sub> was 0.98 (95% CI: 0.93-1.04, p < .01) mV larger than corresponding BV<sub>c</sub> , and 0.27 (95% CI: 0.16-0.37, p < .01) mV larger than matching BVp in sinus rhythm, with higher percentage differences in low voltage regions, leading to smaller endocardial dense scar (2.3 [2.7] vs. 12.1 [17] cm<sup>2</sup> , p < .01) and border zone (3.2 [7.4] vs. 4.8 [20.1] cm<sup>2</sup> , p = .03) regions in microbipolar maps compared to standard bipolar maps. Late potentials areas were nonsignificantly greater in microelectrode maps, compared to standard electrode maps. At sites of VT termination (n = 14), μBE were of higher amplitude (0.9 [0.8] vs. 0.4 [0.2] mV, p < .01), longer duration (117 [66] vs. 74 [38] ms, p < .01), and with greater number of peaks (4 [2] vs. 2 [1], p < .01) in sinus rhythm compared to BE.<br /><b>Conclusion</b><br />microelectrode mapping is more sensitive than standard bipolar mapping in the identification of viable myocytes in SR, and may facilitate recognition of targets for CA.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 23 Apr 2023; epub ahead of print</small></div>

<div><h4>Watchman device migration and embolization: A report from the NCDR LAAO Registry.</h4><i>Friedman DJ, Freeman JV, Zimmerman S, Tan Z, ... Faridi KF, Curtis JP</i><br /><b>Introduction</b><br />Incomplete anchoring of the Watchman left atrial appendage closure (LAAO) device can result in substantial device migration or device embolization (DME) requiring percutaneous or surgical retrieval.<br /><b>Methods</b><br />We performed a retrospective analysis of Watchman procedures (January 2016 through March 2021) reported to the National Cardiovascular Data Registry LAAO Registry. We excluded patients with prior LAAO interventions, no device released, and missing device information. In-hospital events were assessed among all patients and postdischarge events were assessed among patients with 45-day follow-up.<br /><b>Results</b><br />Of 120 278 Watchman procedures, the in-hospital DME rate was 0.07% (n = 84) and surgery was commonly performed (n = 39). In-hospital mortality rate was 14% among patients with DME and 20.5% among patients who underwent surgery. In-hospital DME was more common: at hospitals with a lower median annual procedure volume (24 vs. 41 procedures, p < .0001), with Watchman 2.5 versus Watchman FLX devices (0.08% vs. 0.04%, p = .0048), with larger LAA ostia (median 23 vs. 21 mm, p = .004), and with a smaller difference between device and LAA ostial size (median difference 4 vs. 5 mm, p = .04). Of 98 147 patients with 45-day follow-up, postdischarge DME occurred in 0.06% (n = 54) patients and cardiac surgery was performed in 7.4% (n = 4) of cases. The 45-day mortality rate was 3.7% (n = 2) among patients with postdischarge DME. Postdischarge DME was more common among men (79.7% of events but 58.9% of all procedures, p = .0019), taller patients (177.9 vs. 172 cm, p = .0005), and those with greater body mass (99.9 vs. 85.5 kg, p = .0055). The rhythm at implant was less frequently AF among patients with DME compared to those without (38.9% vs. 46.9%, p = .0098).<br /><b>Conclusion</b><br />While Watchman DME is rare, it is associated with high mortality and frequently requires surgical retrieval, and a substantial proportion of events occur after discharge. Due to the severity of DME events, risk mitigation strategies and on-site cardiac surgical back-up are of paramount importance.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 20 Apr 2023; epub ahead of print</small></div>

<div><h4>The role of trigger factors in the occurrence of appropriate ICD shocks and their clinical and prognostic implications.</h4><i>Lampropoulou E, Kouraki K, Strauss M, Mohammad O, Zahn R, Kleemann T</i><br /><b>Background</b><br />The role of triggers in the occurrence of appropriate implantable cardioverter-defibrillator (ICD) shocks due to ventricular tachyarrhythmias is not well known. The aim of the study was to assess the prevalence of trigger factors in appropriate ICD shocks and to analyze their prognostic impact on clinical outcome.<br /><b>Methods</b><br />A total of 710 consecutive patients of a prospective single-center ICD-registry who received a first appropriate ICD shock between 2000 and 9/2021 were analyzed.<br /><b>Results</b><br />In 35% of ICD patients with first ICD shock, at least one of the following triggers was found: Ischemia (22%), Compliance (9%), Decompensation (38%), Stress (12%), Technical (5%), Electrolyte/endocrinological disorder (22%) and Medication side effects (4%). The trigger factors can be summarized under the acronym ICD-STEMi. The prospective application of the ICD-STEMi scheme increased the rate of identified triggers from 32% to 56% (p < .001). Patients with triggered first ICD shock had an increased 5-year mortality rate (50% vs. 38%, p < .001). Patients with triggers did not show different mortality outcomes or recurrent ICD shocks whether they received arrhythmia therapy or not.<br /><b>Conclusions</b><br />The evaluation of trigger factors after the occurrence of ICD shocks is mandatory and can be systematically evaluated using the acronym ICD-STEMi. Systematic evaluation of triggers using the ICD-STEMi scheme can identify triggers in about half of ICD patients with first appropriate ICD shock. Patients with triggered ICD shock have a 12% higher 5-year mortality rate.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 16 Apr 2023; epub ahead of print</small></div>

<div><h4>Insight of electrocardiographic and electrophysiological parameters on the left ventricular function in patients with ventricular arrhythmia from left ventricular summit.</h4><i>Kuo MJ, Lin CY, Lin YJ, Chang SL, ... Liu SH, Chen SA</i><br /><b>Introduction</b><br />Ventricular arrhythmia (VA) commonly originate from the left ventricular summit (LVS) and results in left ventricular (LV) dysfunction in some patients; however, factors related to LV cardiomyopathy have not been well elucidated. Therefore, this study aimed to investigate the risk factors for LV cardiomyopathy and the outcomes of patients with LVS VA.<br /><b>Methods</b><br />Between 2013 and 2018, a total of 139 patients (60.7% men; mean age 53.2 ± 13.9 years old) underwent catheter ablation for LVS VA in two centers. Detailed patient demographics, electrocardiograms, electrophysiological characteristics, and clinical outcomes were analyzed. LV cardiomyopathy was defined as left ventricular ejection fraction (LVEF) <50%.<br /><b>Results</b><br />Acute procedural success was achieved in 92.8% of patients. There were 40 patients (28.8%) with LV cardiomyopathy, and the mean LVEF improved from 37.5 ± 9.3% to 48.5 ± 10.2% after ablation (p < .001). After multivariate analysis, the independent factors of LV dysfunction were wider QRS duration (QRSd) of the VA (odds ratio [OR] 1.02; 95% confidence interval [CI]: 1.00-1.04; p = .046) and the absolute earliest activation time discrepancy (AEAD) between epicardium and endocardium (OR 1.05; 95% CI: 1.00-1.09; p = .048). After ablation, the LV function was completely recovered in 20 patients (50%). The factors for LV dysfunction without recovery included wider premature ventricular complex (PVC) QRSd (OR 1.09; 95% CI: 1.02-1.17; p = .012) and poorer LVEF (OR 0.85; 95% CI: 0.74-0.97; p = .020).<br /><b>Conclusion</b><br />In patients with VA from the LVS, PVC QRSd and AEAD are factors associated with deteriorating LV systolic function. Catheter ablation can reverse LV remodeling. Narrower QRSd and better LVEF are associated with better recovery of LV function after ablation.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 16 Apr 2023; epub ahead of print</small></div>

<div><h4>Novel use of an irrigated ablation catheter to monitor real-time hemodynamics during ablation.</h4><i>Bhatia NK, Iravanian S, Ravi N, Kiani S, ... Hoque A, Shah AD</i><br /><b>Introduction</b><br />Hemodynamic decompensation during catheter ablation occurs due to prolonged procedure time and irrigant delivery directly into the cardiac chambers. Real-time hemodynamic monitoring of patients undergoing catheter ablation procedures may identify patients at risk of decompensation; we set out to assess the feasibility of a novel, real-time, intracardiac pressure monitoring system using a standard irrigated ablation catheter.<br /><b>Methods</b><br />We studied 13 consecutive who underwent pressure measurement of the left atrium (LA) and left ventricle (LV) via transeptal access with a Swan Ganz (SG) catheter followed by two commercially available irrigated ablation catheters. Pressure waveform data was extracted to compare LA peak pressure, LV peak systolic pressure, LV end-diastolic pressure, and waveform analysis.<br /><b>Results</b><br />Comparison between the SG and ablation catheters (AblA; AblB) demonstrated that LV systolic pressure (0.61-16.8 mmHg; 1.32-18.2 mmHg), and LV end-diastolic pressure (-3.4 to 2.8 mmHg; -3.0 to 3.35 mmHg) were well correlated and had accepted repeatability. Ablation waveforms demonstrated an 89.9 ± 6.4% correlation compared to SG waveforms.<br /><b>Conclusion</b><br />Pressure measurements derived from an irrigated ablation catheter are accurate and reliable when compared to an SG catheter. Further studies are needed to determine how real-time pressure monitoring can improve outcomes during ablation procedures.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 10 Apr 2023; epub ahead of print</small></div>

<div><h4>Successful ablation of a right epicardial accessory pathway via the right ventricular diverticulum in a patient with Wolff-Parkinson-White syndrome.</h4><i>Zhang Z, Ma C, Li X, Qu L, Zhao B, Bai R</i><br /><b>Introduction</b><br />We describe one rare case of successful ablation of a right epicardial accessory pathway (AP) via the right ventricular diverticulum in a patient with Wolff-Parkinson-White syndrome.<br /><b>Methods</b><br />A 42-year-old woman being referred to the hospital for a catheter ablation of a Wolf-Parkinson White syndrome. Earliest activation was shown to be present in the region of the tricuspid annulus. However, ablation had no effect on the AP.<br /><b>Results</b><br />We decided to do a selected angiography, in which a big diverticulum near to the right tricuspid annulus was shown to be present. Ablation in this region successfully repressed the AP without any recurrences within a follow-up period of 12 months.<br /><b>Conclustion</b><br />The ventricular diverticulum mediated AP is a novel variant of pre-excitation. It can serve as an anatomical substrate of supraventricular tachycardia, and can be ablated endocardially using an irrigation tip catheter within the diverticulum. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 01 Apr 2023; epub ahead of print</small></div>

<div><h4>Pulsed-Field-Ablation for the Treatment of Atrial Fibrillation in Patients with Congenital Anomalies of Cardiac Veins.</h4><i>Castiglione A, Küffer T, Gräni C, Servatius H, Reichlin T, Roten L</i><br /><b>Introduction</b><br />Anomalous cardiac veins are not rare and pulmonary vein (PV) isolation for atrial fibrillation (AF) treatment should include these veins. Pulsed-field ablation (PFA) is a novel technology for AF ablation with excellent efficacy and safety profile. In this case series, we describe our first experience of isolation of anomalous cardiac veins using PFA in patients with AF.<br /><b>Methods</b><br />We report a series of patients with congenital anomalies of the cardiac veins and AF, treated with PFA. All patients underwent cardiac computed tomography for procedural planning.<br /><b>Results</b><br />We included five patients (4 males). Anomalous cardiac veins included a connection of a left common ostium to the coronary sinus, a partial and a complete drainage of the right superior PV into the superior vena cava (SVC) with and without additional atrial septal defect, a persistent left SVC and an anomalous posterior PV. All anomalous PVs were isolated using PFA. No phrenic nerve palsy or other complications occurred. PFA of an abnormal right superior PV draining into the distal SVC was possible without affecting the sinus node. After a median of four months, four patients were free of recurrence. One patient had recurrent AF and perimitral reentry tachycardia, probably facilitated by PFA in the mitral isthmus region during isolation of an anomalous connection of the left common ostium to the coronary sinus.<br /><b>Conclusions</b><br />Using systematic pre-procedural imaging and 3D-electroanatomic mapping, the currently available PFA system seems well suited, efficient and versatile for the treatment of AF in patients with anomalous cardiac veins. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 01 Apr 2023; epub ahead of print</small></div>

<div><h4>Selection of Patients for Hybrid Ablation Procedure.</h4><i>De Lurgio DB</i><br /><AbstractText>Catheter ablation for treatment of symptomatic non-paroxysmal atrial fibrillation remains challenging. Clinical failure and need for continued medical therapy or repeat ablation is common, especially in more advanced forms of atrial fibrillation. Hybrid ablation has emerged as a more effective and safe therapy than endocardial-only ablation particularly for longstanding persistent atrial fibrillation as demonstrated by the randomized controlled CONVERGE trial. Hybrid ablation requires collaboration of electrophysiologists and cardiac surgeons to develop specific workflows. This review describes the Hybrid Convergent approach in the context of available ablation options and offers guidance for workflow development and patient selection. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 01 Apr 2023; epub ahead of print</small></div>

<div><h4>Implantable Defibrillator-Detected Heart Failure Status Predicts Ventricular Tachyarrhythmias.</h4><i>Compagnucci P, Casella M, Bianchi V, Franculli F, ... Guerra F, Russo AD</i><br /><b>Background:</b><br/>and aims</b><br />the prediction of ventricular tachyarrhythmias among patients with implantable cardioverter defibrillators is difficult with available clinical tools. We sought to assess whether in patients with heart failure and reduced ejection fraction with defibrillators, physiological sensor-based heart failure status, as summarized by the HeartLogic index, could predict appropriate device therapies.<br /><b>Methods</b><br />568 consecutive HF patients with defibrillators (n=158, 28%) or cardiac resynchronization therapy-defibrillators (n=410, 72%) were included in this prospective observational multicenter analysis. The association of both HeartLogic index and its physiological components with defibrillator shocks and overall appropriate therapies was assessed in regression and time-dependent Cox models.<br /><b>Results</b><br />Over a follow-up of 25 [15-35] months, 122 (21%) patients received an appropriate device therapy (shock, n=74, 13%), while the HeartLogic index crossed the threshold value (alert, HeartLogic ≥16) 1200 times (0.71 alerts/patient-year) in 370 (65%) subjects. The occurrence of ≥1 HeartLogic alert was significantly associated with both appropriate shocks (HR: 2.44, 95% CI: 1.49-3.97, p=0.003), and any appropriate defibrillator therapies. In multivariable time-dependent Cox models, weekly IN-alert state was the strongest predictor of appropriate defibrillator shocks (HR: 2.94, 95%CI: 1.73-5.01, p<0.001) and overall therapies. Compared to stable patients, patients with appropriate shocks had significantly higher values of HeartLogic index, third heart sound amplitude, and resting heart rate 30-60 days prior to device therapy.<br /><b>Conclusions</b><br />The HeartLogic index is an independent dynamic predictor of appropriate defibrillator therapies. The combined index and its individual physiological components change before the arrhythmic event occurs. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 30 Mar 2023; epub ahead of print</small></div>

<div><h4>Defining dyssynchrony: The ongoing search for cardiac resynchronization therapy \"response\".</h4><i>Mareddy C, Mason PK</i><br /><AbstractText>The first trial to demonstrate the benefits of cardiac resynchronization therapy (CRT) was published in 2001. The single-blind crossover study demonstrated significant improvement in quality of life, NYHA class, and 6 minute walk test for patients with a left ventricular ejection fraction less than 35%, NYHA class III, an enlarged left ventricle, and a QRS duration greater than 150 ms.<sup>1</sup> CRT represented an exciting advancement in cardiac implantable electronic device (CIED) therapy. While implantable cardioverter defibrillators (ICDs) had been in use for decades and represented a reliable, life-saving measure to treat fatal ventricular arrhythmias, for the first time, there was a device therapy that could improve quality of life for heart failure patients. The CARE-HF trial went on to demonstrate reduction in hospitalization and mortality in a similar population, and subsequent studies, such as MADIT-CRT suggested that the benefits extended to patients with NYHA class I or II.<sup>2,3</sup> This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 30 Mar 2023; epub ahead of print</small></div>

<div><h4>Ventricular Arrhythmias in Patients with Prior Aortic Valve Intervention: Characteristics, Ablation and Outcomes.</h4><i>Khalil F, Toya T, Ahmad A, Siontis KC, ... Asirvatham SJ, Killu AM</i><br /><b>Background</b><br />Data regarding ventricular tachycardia (VT) or premature ventricular complex (PVC) ablation in patients with aortic valve intervention (AVI) is limited. Catheter ablation (CA) can be challenging given perivalvular substrate in the setting of prosthetic valves.<br /><b>Objective</b><br />To investigate the characteristics, safety, and outcomes of CA in patients with prior AVI and ventricular arrhythmias (VA).<br /><b>Methods</b><br />We identified consecutive patients with prior AVI (replacement or repair) who underwent CA for VT or PVC between 2013 and 2018. We investigated the mechanism of arrhythmia, ablation approach, perioperative complications, and outcomes.<br /><b>Results</b><br />We included 34 patients (88% men, mean age 64±10.4 years, left ventricular ejection fraction 35.2±15.0%) with prior AVI who underwent CA (22 VT; 12 PVC). LV access was obtained through trans-septal approach in all patients except one patient who had percutaneous transapical access. One patient had combined retrograde aortic and trans-septal approach. Scar-related reentry was the dominant mechanism of induced VTs. Two patients had bundle branch reentry VTs. In the VT group, substrate mapping demonstrated heterogeneous scar that involved the periaortic valve area in 95%. Despite that, the site of successful ablation included the periaortic region only in 6 (27%) patients. In the PVC group, signal abnormalities consistent with scar in the periaortic area were noted in 4 (33%) patients. In 8 (67%) patients, the successful site of ablation was unrelated to the periaortic area. No procedure-related complications occurred. The survival and recurrence-free survival rate at 1 year tended to be lower in VT group than in PVC group (P=0.06 and P=0.05, respectively) with a 1-year recurrence-free survival rate of 52.8% and 91.7%, respectively. No arrhythmia-related death was documented on long-term follow-up.<br /><b>Conclusion</b><br />CA of VAs can be performed safely and effectively in patients with prior AVI. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 30 Mar 2023; epub ahead of print</small></div>

<div><h4>Cardioneuroablation for treatment of carotid sinus syndrome secondary to orofarengeal squamoz cell cancer.</h4><i>Bozyel S, Güler TE, Çelik M, Dalgıç N, ... Çağdaş M, Aksu T</i><br /><b>Introduction</b><br />Cardioneuroablation may be an alternative to pacing therapy to treat carotid sinus syndrome secondary to inoperable head and neck tumors.<br /><b>Methods</b><br />We performed, bi-atrial electroanatomic-mapping-guided (a fractionated electrogram-based) cardioneuroablation treatment.<br /><b>Results</b><br />Ablation procedure led to an increase in resting sinus heart rhythm (from 54 to 81 bpm). During the follow-up period of approximately 6 months, neither any bradycardia episodes (sinus bradycardia, sinus pause, AV block, etc.) nor any symptoms were observed in the patient.<br /><b>Conclusion</b><br />In this case, we performed successful cardioneuroablation therapy for the first time in a patient with carotid sinus syndrome secondary to oropharyngeal squamous cell carcinoma. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 23 Mar 2023; epub ahead of print</small></div>

<div><h4>SGLT2 Inhibitors Reduce Sudden Cardiac Death Risk in Heart Failure: Meta-analysis of Randomized Clinical Trials.</h4><i>Oates CP, Santos-Gallego CG, Smith A, Basyal B, ... Reddy VY, Koruth JS</i><br /><b>Background</b><br />Multiple randomized controlled trials have demonstrated sodium-glucose cotransporter-2 inhibitors (SGLT2i) decrease the composite endpoint of cardiovascular death or heart failure hospitalizations in all heart failure patients. It is uncertain whether SGLT2i impacts the risk of sudden cardiac death in patients with heart failure.<br /><b>Objective</b><br />To assess the impact of SGLT2i therapy on arrhythmic outcomes in patients with heart failure receiving optimal medical therapy.<br /><b>Methods</b><br />A comprehensive search was performed to identify relevant data published prior to August 28, 2022. Trials were included if: 1) all patients had clinical heart failure 2) SGLT2i and placebo were compared 3) all patients received conventional medical therapy and 4) reported outcomes of interest (SCD, ventricular arrhythmias, atrial arrhythmias).<br /><b>Results</b><br />SCD was reported in seven of the eleven trials meeting selection criteria: 10,796 patients received SGLT2i and 10,796 received placebo. SGLT2i therapy was associated with a significant reduction in the risk of SCD (RR 0.68; 95% CI 0.48-0.95; p = 0.03; I2 = 0%). Absent dedicated rhythm monitoring, there were no significant differences in the incidence of sustained ventricular arrhythmias not associated with SCD (RR 1.03; 95% CI, 0.83-1.29; p = 0.77; I2 = 0%) or atrial arrhythmias (RR 0.91; 95% CI, 0.77-1.09; p = 0.31; I2 = 29%) between patients receiving an SGLT2i vs placebo.<br /><b>Conclusion</b><br />SGLT2i therapy is associated with a reduced risk of SCD in patients with heart failure receiving contemporary medical therapy. Prospective trials are needed to determine the long-term impact of SGLT2i therapy on atrial and ventricular arrhythmias. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 23 Mar 2023; epub ahead of print</small></div>

<div><h4>Accuracy of the Apple Watch for Detection of AF: A Multi-Center Experience.</h4><i>Wasserlauf J, Vogel K, Whisler C, Benjamin E, ... Yousuf O, Passman RS</i><br /><b>Background</b><br />The Apple Watch (AW) Irregular Rhythm Notification (IRN) feature uses photoplethysmography to identify prolonged episodes of irregular rhythm suggestive of atrial fibrillation (AF). IRN is FDA cleared for those with no previous history of AF, however, these devices are increasingly being used for AF management.<br /><b>Objective</b><br />To determine the accuracy of the IRN in subjects with a previous diagnosis of non-permanent AF.<br /><b>Methods</b><br />Subjects with a history of non-permanent AF and either an insertable cardiac monitor (ICM) or cardiac implanted electronic device (CIED) with < 5% ventricular pacing were fitted with an AW Series 5 for 6 months. AF episodes were compared between the ICM/CIED and IRN. The primary endpoints were sensitivity, specificity, PPV, and NPV of the IRN by subject for AF ≥ 1 hour. Secondary endpoints were sensitivity and PPV by AF episode ≥ 1 hour. Analysis was limited to a maximum of 10 ICM/CIED episodes per subject and included only those AF episodes occurring during active AW use confirmed by activity data.<br /><b>Results</b><br />Thirty participants, mean age was 65.4y ± 12.2y, 40% female, were enrolled. There were 10 ICMs and 20 CIEDs. 11 subjects had AF on ICM/CIED while the AW was worn, of whom 8 were detected by IRN. There were no false positive IRN detections by subject (\"by subject\" 72% sensitivity, 100% specificity, 100% PPV, and 90% NPV). 5 subjects had AF only when the AW was not worn. There were a total of 70 AF episodes on ICM/CIED, 35 of which occurred while the AW was being worn. Of these, 21 were detected by IRN with 1 false positive (\"by episode\" sensitivity = 60.0%, PPV = 95.5%).<br /><b>Conclusion</b><br />In a population with known AF, the AW IRN had a low rate of false positive detections and high specificity. Sensitivity for detection by subject and by AF episode was lower. The current IRN algorithm appears accurate for AF screening as currently cleared, but increased sensitivity and wear times would be necessary for disease management. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 21 Mar 2023; epub ahead of print</small></div>

<div><h4>Ultrasound guidance for femoral venous access in patients undergoing pulmonary vein isolation: a quasi-randomized study.</h4><i>Kupo P, Riesz TJ, Saghy L, Vamos M, ... Miklos M, Pap R</i><br /><b>Introduction</b><br />Routine ultrasound (US)-guidance for femoral venous access to decrease vascular complications of atrial fibrillation (AF) ablation procedures has been advocated. However, the benefit has not been unequivocally demonstrated by randomized-trial data.<br /><b>Methods and results</b><br />Consecutive patients undergoing pulmonary vein isolation (PVI) on uninterrupted anticoagulant treatment were included. A quasi-random allocation to either US-guided or conventional puncture group was based on which of the two procedure rooms the patient was scheduled in, with only one of the rooms equipped with an US machine including a vascular transducer. The same 4 novice operators in rotation, with no relevant previous experience in US-guided vascular access performed venous punctures in both rooms. Major and minor vascular complications and the rate of prolonged hospitalization were compared. Major vascular complication was defined as groin hematoma, arteriovenous fistula, or pseudoaneurysm. Hematoma was considered as a major vascular complication if it met type 2 or higher Bleeding Academic Research Consortium criteria (requiring nonsurgical, medical intervention by a health care professional; leading to hospitalization or increased level of care, or prompting evacuation). Of the 457 patients 199 were allocated to the US-guided puncture group, while the conventional, palpation-based approach was performed in 258 cases. Compared to the conventional technique, US-guidance reduced the rate of any vascular complication (11.63% vs. 2.01%, p<0.0001), including both major (4.26% vs. 1.01%, p=0.038) and minor (7.36% vs 1.01%, p=0.001) vascular complications. In addition, the rate of prolonged hospitalization was lower in the US-guided puncture group (5.04% vs. 1.01%, p=0.032).<br /><b>Conclusion</b><br />The use of US for femoral vein puncture in patients undergoing PVI decreased the rate of both major and minor vascular complications. This quasi-randomized comparison strongly supports adapting routine use of US for AF ablation procedures. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 21 Mar 2023; epub ahead of print</small></div>

<div><h4>Short RP tachycardia with Concentric atrial activation: What is the mechanism?</h4><i>Ghosh A, Das D, Sriram CS, Pandurangi UM</i><br /><AbstractText>A 50-year old man with a structurally normal heart presented with recurrent palpitations for six months. This was in spite of a recent radiofrequency ablation at another center for a presumed diagnosis of atrio-ventricular nodal reentrant tachycardia (AVNRT). Interestingly, his first radiofrequency ablation for a tachyarrhythmia was over a decade ago, but records were unavailable. The 12 lead Electrocardiogram (ECG) revealed a short RP tachycardia at rate of 170 bpm. There was no preexcitation during sinus rhythm. Baseline intervals were normal during the ensuing electrophysiology study (EPS). The catheter positions with the annotations His (His bundle), CS (coronary sinus; proximal bipole 9-10 at CS ostium and distal bipole 1-2) and RV (right ventricle apex) are self-explanatory. A regular narrow complex tachycardia with rate related right bundle branch block (CL 280-340 ms, shortest VA 90 ms, and AH 165 ms) was reproducibly induced with a single atrial extra stimulus test (AEST) (Figure 1a). The response to maneuvers performed during tachycardia are denoted: i.e. right ventricular overdrive pacing (VOP) (Figure 1b), His refractory ventricular extra stimulus (HRVES) from the RV (Figure 1c), as well the left ventricular (LV) apex via the radiofrequency ablation catheter (RF 1-2, Figure 1d). What can be deciphered as the mechanism of this tachycardia? This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 19 Mar 2023; epub ahead of print</small></div>

<div><h4>Radiofrequency energy floats, and heat sinks - the effects of convective cooling on lesion formation.</h4><i>Qian PC</i><br /><AbstractText>Radiofrequency (RF) ablation uses alternating electrical current to generate heat at the catheter-tissue interface. The goal is the produce irreversible myocardial tissue injury by raising the tissue temperature above the lethal threshold, variably estimated at approximately 53.6±3.20°C to 60.6 (IQR 59.7-62.4) °C(1,2). Ideally, the tissue temperature should not exceed boiling point and the tissue surface temperature should be kept less than 80°C to avoid complications such as steam pop and coagulum or char formation, respectively. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 19 Mar 2023; epub ahead of print</small></div>

<div><h4>Atrial Fibrillation Ablation Outcome Prediction with a Machine Learning Fusion Framework Incorporating Cardiac Computed Tomography.</h4><i>Razeghi O, Kapoor R, Alhusseini MI, Fazal M, ... Niederer S, Baykaner T</i><br /><b>Background</b><br />Structural changes in the left atrium (LA) modestly predict outcomes in patients undergoing catheter ablation for atrial fibrillation (AF). Machine learning (ML) is a promising approach to personalize AF management strategies and improve predictive risk models after catheter ablation by integrating atrial geometry from cardiac computed tomography (CT) scans and patient-specific clinical data. We hypothesized that ML approaches based on a patient\'s specific data can identify responders to AF ablation.<br /><b>Methods</b><br />Consecutive patients undergoing AF ablation, who had preprocedural CT scans, demographics, and 1-year follow-up data, were included in the study for a retrospective analysis. The inputs of models were CT-derived morphological features from left atrial segmentation (including the shape, volume of the LA, LA appendage, and pulmonary vein ostia) along with deep features learned directly from raw CT images, and clinical data. These were merged intelligently in a framework to learn their individual importance and produce the optimal classification.<br /><b>Results</b><br />321 patients (64.2 + 10.6 years, 69% male, 40% paroxysmal AF) were analyzed. Post 10-fold nested cross-validation, the model trained to intelligently merge and learn appropriate weights for clinical, morphological, and imaging data (AUC 0.821) outperformed those trained solely on clinical data (AUC 0.626), morphological (AUC 0.659) or imaging data (AUC 0.764).<br /><b>Conclusion</b><br />Our machine learning approach provides an end-to-end automated technique to predict AF ablation outcomes using deep learning from CT images, derived structural properties of LA, augmented by incorporation of clinical data in a merged ML framework. This can help develop personalized strategies for patient selection in invasive management of AF. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 19 Mar 2023; epub ahead of print</small></div>

<div><h4>Incidental Left Atrial Appendage Isolation after Catheter Ablation of Persistent Atrial Fibrillation: Mechanisms and Long-term Risk of Thromboembolism.</h4><i>Ghannam M, Jongnarangsin K, Emami H, Yokokawa M, ... Morady F, Chugh A</i><br /><b>Background</b><br />Incidental left atrial appendage (LAA) isolation may occur during radiofrequency ablation of persistent atrial fibrillation (AF).<br /><b>Objective</b><br />The study aims to describe the mechanisms and long-term thromboembolic risk related to incidental LAA isolation.<br /><b>Methods</b><br />Patients who experienced incidental LAA isolation after AF ablation were included. Culprit sites where ablation resulted in LAA isolation were identified. Thromboembolic risk despite oral anticoagulation (OAC) was compared to that in a propensity-matched control group without LAA isolation.<br /><b>Results</b><br />Forty-one patients with LAA isolation, and 82 matched patients without LAA isolation were included. The patient age, ejection fraction, LA diameter, and CHA<sub>2</sub> DS<sub>2</sub> -VASc score were 64±11 years, 55±12%, 45.0±7 mm and 2.62±1.5, respectively. Culprit sites included the LAA base, mitral isthmus, inferior LA, Bachmann\'s bundle, coronary sinus, and Marshall vein. After 4.2±3.6 years follow up, thromboembolism occurred in 7 of 41 patients (17%) with LAA isolation vs. 3 of 82 patients (4%) without isolation (log rank P<0.009, HR 5.14, 95% CI [1.32-19.94], P=0.02). Patients with and without thromboembolism had similar CHA<sub>2</sub> DS<sub>2</sub> -VASc scores (2.65±1.3 vs. 2.71±0.76, P=0.89). Thromboembolism occurred during noncompliance with or temporary discontinuation of OAC in 4 of the 7 patients.<br /><b>Conclusions</b><br />Incidental LAA isolation may occur during ablation of atrial arrhythmias in the vicinity of, or even at sites remote from the appendage. Patients with incidental LAA isolation had higher rates of thromboembolism compared to patients without isolation. Since thromboembolism may occur despite prescription for OAC, the risks of LAA isolation must be weighed against clinical benefit and appendage occlusion devices should be considered in vulnerable patients. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 19 Mar 2023; epub ahead of print</small></div>

<div><h4>FINDING A CAUSE IN SUDDEN CARDIAC ARREST SURVIVORS: GETTING THE TESTING RIGHT.</h4><i>Nalliah C, Raju H, Jagoda C, Semsarian C</i><br /><AbstractText>Sudden cardiac death (SCD) increases with age, with the incidence among persons in their fifth and sixth decades of life reaching 50 per 100,000 patient years. <sup>1</sup> However, SCD and sudden cardiac arrest (SCA) in the young remains one of the most poorly understood causes of death in cardiovascular medicine, comprising a broad range of pathologic entities that encompass both genetic and structural causes. <sup>2</sup> Understanding the fundamental substrate is critical for effective management and prevention of future adverse events. Furthermore, accurate definition of the aetiologic basis has implications for screening and early intervention among other family members. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 19 Mar 2023; epub ahead of print</small></div>

<div><h4>Very High Power Short Duration Ablation: It Takes Two to Make a Thing Go Right?</h4><i>Maidman SD, Barbhaiya CR</i><br /><AbstractText>High power short duration (HPSD) radiofrequency (RF) ablation, utilizing 45-50W for durations of 5-15 seconds per lesion, is increasingly accepted as a safe and effective technique to efficiently achieve pulmonary vein isolation to prevent atrial fibrillation (AF).<sup>1</sup> The next contender in the progression of hotter and faster RF technology is very high power short duration (vHPSD) RF ablation - 90W power for a duration of 4 seconds per lesion - using the QDOT-Micro ablation catheter (Biosense Webster, CA, USA). The catheter is designed to mitigate risks of vHPSD RF ablation by monitoring temperature at the catheter-tissue interface using six thermocouples embedded in the electrode\'s tip which allows for power modulation to maintain a target temperature during RF delivery.<sup>2</sup> Relative to HPSD ablation utilizing 45-50W, vHPSD ablation with 90W may further maximize shallow, resistive heating, while the shorter duration may additionally minimize deep, conductive heating.<sup>2-4</sup> The frequency and risk factors for the feared complications related to ablation, like steam pop, cardiac perforation, or esophageal injury, are not well understood for vHPSD.<sup>5</sup> Early clinical studies of vHPSD ablation reported first pass PVI in approximately 50% of cases, while first pass PVI was achieved in greater frequency with both conventional and HPSD RF ablation using recently described approaches such as the \"CLOSE Protocol\".<sup>5-7</sup> First pass isolation has been shown to be a powerful predictor of procedural efficacy,<sup>3,8,9</sup> thus a greater understanding of the underlying biophysics of lesions created with vHPSD RF ablation may inform optimization of timing and spacing to further improve outcomes for this new technology. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 16 Mar 2023; epub ahead of print</small></div>

<div><h4>Is Brain Natriuretic Peptide specific for the left atrial appendage?</h4><i>Babayiğit E, Karadeniz A, Görenek B</i><br /><AbstractText>We read with great interest the article recently published in Journal of Cardiovascular Electrophysiology, \"Left atrial appendage dimension predicts elevated brain natriuretic peptide in nonvalvular atrial fibrillation\" by Cook JA. et al.<sup>1</sup> The authors have studied the relation between Brain natriuretic peptide (BNP) elevations and left atrial appendage measurements in patients who referred for left atrial appendage (LAA) occlusion in patients with nonvalvular atrial fibrillation (AF) This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 15 Mar 2023; epub ahead of print</small></div>

<div><h4>Evaluation of RETRO-Mapping for Electrophysiological Features including Direction of Plane Activity during Atrial Fibrillation using Multipolar Catheters in Humans.</h4><i>Smith S, Coyle C, Dhutia N, Kanagaratnam P, Linton NWF</i><br /><b>Background</b><br />A quantifiable, automated standard of analysing heart rhythm has long eluded cardiologists due, in part, to the limitations in technology and the ability to analyse large electrogram datasets. In this proof-of-concept study, we propose new measures to quantify plane activity in atrial fibrillation (AF) using our RETRO-Mapping software.<br /><b>Methods</b><br />We recorded 30 second segments of electrograms at the lower posterior wall of the left atrium using a 20-pole double loop catheter (AFocusII). The data were analysed with the custom RETRO-Mapping algorithm in MATLAB. 30 second segments were analysed for number of activation edges, conduction velocity (CV), cycle length (CL), activation edge direction, and wavefront direction. These features were compared across 34613 plane edges in three types of AF: persistent AF treated with amiodarone (11906 wavefronts), persistent AF without amiodarone (14959 wavefronts), and paroxysmal AF (7748 wavefronts). Change in activation edge direction between subsequent frames and change in overall wavefront direction between subsequent wavefronts were analysed.<br /><b>Results</b><br />All activation edge directions were represented across the lower posterior wall. The median change in activation edge direction followed a linear pattern for all three types of AF with R<sup>2</sup> = 0.932 for persistent AF treated without amiodarone, R<sup>2</sup> = 0.942 for paroxysmal AF, and R<sup>2</sup> = 0.958 for persistent AF treated with amiodarone. All medians and the standard deviation error bars remained below 45 degrees (suggesting all activation edges were travelling within a 90-degree sector, a criterion for plane activity). The directions of approximately half of all wavefronts (56.1% for persistent without amiodarone, 51.8% for paroxysmal, 48.8% for persistent with amiodarone) were predictive of the directions of the subsequent wavefront.<br /><b>Conclusions</b><br />RETRO-Mapping can measure electrophysiological features of activation activity and this proof-of-concept study suggests that this can be extended to the detection of plane activity in three types of AF. Wavefront direction may have a role in future work for predicting plane activity. For this study, we focused more on the ability of the algorithm to detect plane activity and less the differences between the types of AF. Future work should be in validating these results with a larger dataset and comparing with other types of activation such as rotational, collision, and focal. Ultimately, this work can be implemented in real-time for prediction of wavefronts during ablation procedures. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 11 Mar 2023; epub ahead of print</small></div>

<div><h4>Comparison of the relation of the ESC 2021 and ESC 2013 definitions of Left Bundle Branch Block with clinical and echocardiographic outcome in cardiac resynchronization therapy.</h4><i>Rijks J, Ghossein MA, Wouters PC, Dural M, ... Vernooy K, van Stipdonk AMW</i><br /><b>Aims</b><br />We aimed to investigate the impact of the 2021 ESC guideline changes in left bundle branch block(LBBB) definition on cardiac resynchronization therapy(CRT) patient selection and outcomes.<br /><b>Methods</b><br />The MUG(Maastricht-Utrecht-Groningen) registry, consisting of consecutive patients implanted with a CRT device between 2001 and 2015 was studied. For this study, patients with baseline sinus rhythm and QRS duration >130ms were eligible. Patients were classified according to ESC 2013 and 2021 guideline LBBB definitions and QRS duration. Endpoints were heart transplantation, LVAD implantation or mortality(HTx/LVAD/mortality) and echocardiographic response(LVESV reduction >15%).<br /><b>Results</b><br />The analyses included 1.202, typical CRT patients. The ESC 2021 definition resulted in considerably less LBBB diagnoses compared to the 2013 definition(31.6% vs 80.9%, respectively). Applying the 2013 definition resulted in significant separation of the Kaplan Meier curves of HTx/LVAD/mortality(p<0.0001). A significantly higher echocardiographic response rate was found in the LBBB compared to the non-LBBB group using the 2013 definition. These differences in HTx/LVAD/mortality and echocardiographic response were not found when applying the 2021 definition.<br /><b>Conclusion</b><br />The ESC 2021 LBBB definition leads to a considerably lower percentage of patients with baseline LBBB then the ESC 2013 definition. This does not lead to better differentiation of CRT responders, nor does this lead to a stronger association with clinical outcomes after CRT. In fact, stratification according to the 2021 definition is not associated with a difference in clinical or echocardiographic outcome, implying that the guideline changes may negatively influence CRT implantation practice with a weakened recommendation in patients that will benefit from CRT. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 11 Mar 2023; epub ahead of print</small></div>

<div><h4>Conduction System versus Biventricular Pacing in Heart Failure with non-Left Bundle Branch Block.</h4><i>Tan ES, Soh R, Lee JY, Boey E, ... Seow SC, Kojodjojo P</i><br /><b>Introduction</b><br />The benefits of cardiac resynchronization therapy (CRT) with biventricular pacing (BiV) is significantly lower when applied to heart failure (HF) patients with non-left bundle branch block (LBBB) conduction delay. We investigated clinical outcomes of conduction system pacing (CSP) for CRT in non-LBBB HF.<br /><b>Methods</b><br />Consecutive HF patients with non-LBBB conduction delay undergoing CSP were propensity matched for age, sex, HF-etiology and atrial fibrillation (AF) in a 1:1 ratio to BiV from a prospective registry of CRT recipients. Echocardiographic response was defined as an increase in left ventricular ejection fraction (LVEF) by ≥10%. The primary outcome was the composite of HF-hospitalizations or all-cause mortality.<br /><b>Results</b><br />96 patients were recruited (mean age 70±11years, 22% female, 68% ischemic HF and 49% AF). Significant reductions in QRS duration and LV dimensions were seen only after CSP, while LVEF improved significantly in both groups (p<0.05). Echocardiographic response occurred more frequently in CSP than BiV (51% vs 21%, p<0.01), with CSP independently associated with 4-fold increased odds (adjusted odds ratio 4.08, 95% confidence interval [CI] 1.34-12.41). The primary outcome occurred more frequently in BiV than CSP (69% vs 27%, p<0.001), with CSP independently associated with 58% risk reduction (adjusted hazard ratio[AHR] 0.42, 95%CI 0.21-0.84, p=0.01), driven by reduced all-cause mortality (AHR 0.22, 95%CI 0.07-0.68, p<0.01), and a trend towards reduced HF-hospitalization (AHR 0.51, 95%CI 0.21-1.21, p=0.12).<br /><b>Conclusions</b><br />CSP provided greater electrical synchrony, reverse remodelling, improved cardiac function and survival compared to BiV in non-LBBB, and may be the preferred CRT strategy for non-LBBB HF. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 11 Mar 2023; epub ahead of print</small></div>

<div><h4>Comparison of lesion characteristics using temperature-flow-controlled versus conventional power-controlled ablation with fixed ablation index.</h4><i>Ikenouchi T, Takigawa M, Goya M, Martin CA, ... Miyazaki S, Sasano T</i><br /><b>Purpose</b><br />The QDOT-Micro<sup>TM</sup> catheter is a novel irrigated contact force (CF) sensing catheter which benefits from thermocouples for temperature monitoring, allowing temperature-flow-controlled (TFC) ablation. We compared lesion metrics at fixed ablation index (AI) value during TFC-ablation and conventional power-controlled (PC)-ablation.<br /><b>Methods</b><br />A total of 480 RF-applications were performed on ex-vivo swine myocardium with predefined AI targets (400/550) or until steam-pop occurred, using the QDOT-Micro<sup>TM</sup> (TFC-ablation) and Thermocool SmartTouch SF<sup>TM</sup> (PC-ablation).<br /><b>Results</b><br />Both TFC-ablation and PC-ablation produced similar lesions in volume (218±116 vs 212±107 mm<sup>3</sup> , p=0.65); however, lesions using TFC-ablation were larger in surface area (41.3±8.8 vs 34.8±8.0 mm<sup>2</sup> , p<0.001) and shallower in depth (4.0±1.0 vs 4.2±1.1 mm, p=0.044). Average power tended to be lower in TFC-alation (34.2±8.6 vs 36.9±9.2, p=0.005) compared to PC-ablation due to automatic regulation of temperature and irrigation-flow. Although steam-pops were less frequent in TFC-ablation (24% vs 15%, p=0.021), they were particularly observed in low-CF (10g) and high-power ablation (50W) in both PC-ablation (n=24/240, 10.0%) and TFC-ablation (n=23/240, 9.6%). Multivariate analysis revealed that high-power, low-CF, long application time, perpendicular catheter orientation, and PC-ablation were risk factors for steam-pops. Furthermore, activation of automatic regulation of temperature and irrigation-flow was independently associated with high-CF and long application time while ablation power had no significant relationship.<br /><b>Conclusions</b><br />With a fixed target AI, TFC-ablation reduced the risk of steam-pops, producing similar lesions in volume, but with different metrics in this ex-vivo study. However, lower CF and higher power in fixed-AI ablation may increase the risk of steam-pops. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 11 Mar 2023; epub ahead of print</small></div>

<div><h4>Effect of Sacubitril Valsartan on the Incidence of Atrial Fibrillation: A Meta-Analysis.</h4><i>Mohammad Z, Ahmad J, Sultan A, Penagaluri A, Morin D, Dominic P</i><br /><b>Introduction</b><br />Sacubitril/valsartan reduces all-cause mortality in heart failure (HF) patients compared to angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs). ACEIs/ARBs have been shown to decrease the incidence of atrial fibrillation (AF). We hypothesized sacubitril-valsartan decreases the incidence of AF compared to ACEis/ARBs.<br /><b>Methods</b><br />Clinicaltrials.gov was searched for trials by terms sacubitril/valsartan, entresto, sacubitril, valsartan. Randomized controlled human trials of sacubitril/valsartan reporting AF were included. Data were extracted independently by two reviewers. Data was pooled using a random effect model. Publication bias was evaluated by funnel plots.<br /><b>Results</b><br />A total of 11 trials including 11,458 patients on sacubitril/valsartan and 10,128 patients on ACEI/ARBs were identified. 284 AF events were reported in the sacubitril/valsartan group compared to 256 AF events in ACEIs/ARBs. Patients on sacubitril/valsartan were as likely as patients on ACEIs/ARBs to develop AF (pooled OR=1.091, 95% CI= 0.917 - 1.298, p=0.324). 6 Atrial flutter (AFl) events were reported in 6 trials; 48 out of 9165 patients in the sacubitril/valsartan group developed AFl compared to 46 out of 8759 in ACEi/ARBs group. There was no difference in AFl risk between the two groups (pooled OR=1.028, 95% CI=0.681 - 1.553, p=0.894). Finally, sacubitril/valsartan did not reduce the risk of atrial arrhythmias (AF+AFl) compared to ACEi/ARBs (pooled OR=1.081, 95% CI= 0.922 - 1.269, p=0.337).<br /><b>Conclusion</b><br />Although sacubitril/valsartan reduces mortality compared to ACEIs/ARBs in HF patients, they do not reduce AF risk compared to these drugs. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 05 Mar 2023; epub ahead of print</small></div>

<div><h4>Differences in Post Ablation Cardiac MRI Scar Between Radiofrequency and Cryoballoon Ablation: A DECAAF II Sub-analysis.</h4><i>Nelson DW, Dhorepatil A, Kreidieh O, Mekhael M, ... Feng H, Marrouche N</i><br /><b>Introduction</b><br />Pulmonary vein isolation (PVI) using radiofrequency (RF) and cryoballoon (Cryo) ablation are standard approaches for rhythm control in patients with symptomatic atrial fibrillation. Both strategies create scar in the left atrium (LA). There have been few studies investigating the difference in scar formation between patients undergoing RF and Cryo using cardiac magnetic resonance imaging (CMR).<br /><b>Methods</b><br />The current study is a sub-analysis of the control arm of the Delayed-Enhancement MRI Determinant of Successful Catheter Ablation of Atrial Fibrillation study (DECAAF II). The study was a multicenter, randomized, controlled, single blinded trial that evaluated atrial arrhythmia recurrence (AAR) between PVI alone and PVI plus CMR atrial fibrosis guided ablation. Pre-ablation CMR and 3-6-month post ablation CMR were obtained to assess baseline LA fibrosis and scar formation respectively.<br /><b>Results</b><br />Of the 843 patients randomized in the DECAAF II trial, we analyzed the 408 patients in the primary analysis control arm that received standard PVI. Five patients received combined RF and Cryo ablations so were excluded from this sub-analysis. Of the 403 patients analyzed, 345 underwent RF and 58 Cryo. The average procedure duration was 146 minutes for RF and 103 minutes for Cryo (p = 0.001). The rate of AAR at ~15 months occurred in 151 (43.8%) patients in the RF group and 28 (48.3%) patients in the Cryo group (p = 0.62). On 3-month post CMR the RF arm had significantly more scar (8.8% vs. 6.4%, p = 0.001) compared to Cryo. Patients with ≥ 6.5% LA scar (p < 0.001) and ≥ 2.3% LA scar around the PV antra (p = 0.01) on 3-month post CMR had less AAR independent of ablation technique. Cryo caused a greater percentage of right and left pulmonary vein (PV) antral scar (p = 0.04, p = 0.02) and less non-PV antral scar (p = 0.009) compared to RF. On Cox regression Cryo patients free of AAR had a greater percentage of left PV antral scar (p = 0.01) and less non-PV antral scar (p = 0.004) compared to RF free of AAR.<br /><b>Conclusion</b><br />In this sub-analysis of the control arm of the DECAAF II trial, we observed that Cryo formed a greater percentage of PV antral scar and less non-PV antral scar compared to RF. Post ablation LA scar ≥ 6.5% predicted freedom from AAR, independent of ablation technique. These findings may have prognostic implications in ablation technique selection and freedom from AAR. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 05 Mar 2023; epub ahead of print</small></div>