<div><h4>Ivabradine for controlling heart rate in permanent atrial fibrillation: A translational clinical trial.</h4><i>Fontenla A, Tamargo J, Salgado R, López-Gil M, ... Bueno H, BRAKE-AF Study Investigators</i><br /><b>Background</b><br />Pharmacological options for rate control in atrial fibrillation are scarce. Ivabradine was postulated to reduce the ventricular rate in this setting.<br /><b>Objectives</b><br />The objectives of this study were to evaluate the mechanism of inhibition of atrioventricular conduction produced by ivabradine and to determine its efficacy and safety in atrial fibrillation.<br /><b>Methods</b><br />The effects of ivabradine on atrioventricular node and ventricular cells were studied by in vitro whole-cell patch-clamp experiments and mathematical simulation of human action potentials. In parallel, a multicenter, randomized, open-label, phase III clinical trial compared ivabradine with digoxin for uncontrolled permanent atrial fibrillation despite β-blocker or calcium channel blocker treatment.<br /><b>Results</b><br />Ivabradine 1 μM inhibited \"funny\" current and rapidly activating delayed rectifier potassium channel current by 28.9% and 22.8%, respectively (P < .05). The sodium channel current and L-type calcium channel current were reduced only at 10 μM. Ivabradine slowed the firing frequency of a modeled human atrioventricular node action potential by 10.6% and induced a minimal prolongation of ventricular action potential. Thirty-five (51.5%) patients were randomized to ivabradine and 33 (49.5%) to digoxin. The mean daytime heart rate decreased by 11.6 beats/min (-11.5%) in the ivabradine arm (P = .02) vs 19.6 (-20.6%) in the digoxin arm (P < .001), although the noninferiority margin of efficacy was not met (Z = -1.95; P = .97). The primary safety end point occurred in 3 patients (8.6%) on ivabradine and in 8 (24.2%) on digoxin (P = .10).<br /><b>Conclusion</b><br />Ivabradine produced a moderate rate reduction in patients with permanent atrial fibrillation. The inhibition of funny current in the atrioventricular node seems to be the main mechanism responsible for this reduction. Compared with digoxin, ivabradine was less effective, was better tolerated, and had a similar rate of serious adverse events.<br /><br />Copyright © 2023 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.<br /><br /><small>Heart Rhythm: 01 Jun 2023; 20:822-830</small></div>

<div><h4>Outcomes After Development of Ventricular Arrhythmias in Single Ventricular Heart Disease Patients With Fontan Palliation.</h4><i>Giacone HM, Chubb H, Dubin AM, Motonaga KS, ... Hanley FL, Chen S</i><br /><b>Background</b><br />With the advent of more intensive rhythm monitoring strategies, ventricular arrhythmias (VAs) are increasingly detected in Fontan patients. However, the prognostic implications of VA are poorly understood. We assessed the incidence of VA in Fontan patients and the implications on transplant-free survival.<br /><b>Methods</b><br />Medical records of Fontan patients seen at a single center between 2002 and 2019 were reviewed to identify post-Fontan VA (nonsustained ventricular tachycardia >4 beats or sustained >30 seconds). Patients with preFontan VA were excluded. Hemodynamically unstable VA was defined as malignant VA. The primary outcome was death or heart transplantation. Death with censoring at transplant was a secondary outcome.<br /><b>Results</b><br />Of 431 Fontan patients, transplant-free survival was 82% at 15 years post-Fontan with 64 (15%) meeting primary outcome of either death (n=16, 3.7%), at a median 4.6 (0.4-10.2) years post-Fontan, or transplant (n=48, 11%), at a median of 11.1 (5.9-16.2) years post-Fontan. Forty-eight (11%) patients were diagnosed with VA (90% nonsustained ventricular tachycardia, 10% sustained ventricular tachycardia). Malignant VA (n=9, 2.0%) was associated with younger age, worse systolic function, and valvular regurgitation. Risk for VA increased with time from Fontan, 2.4% at 10 years to 19% at 20 years. History of Stage 1 surgery with right ventricular to pulmonary artery conduit and older age at Fontan were significant risk factors for VA. VA was strongly associated with an increased risk of transplant or death (HR, 9.2 [95% CI, 4.5-18.7]; <i>P</i><0.001), with a transplant-free survival of 48% at 5-year post-VA diagnosis.<br /><b>Conclusions</b><br />Ventricular arrhythmias occurred in 11% of Fontan patients and was highly associated with transplant or death, with a transplant-free survival of <50% at 5-year post-VA diagnosis. Risk factors for VA included older age at Fontan and history of right ventricular to pulmonary artery conduit. A diagnosis of VA in Fontan patients should prompt increased clinical surveillance.<br /><br /><br /><br /><small>Circ Arrhythm Electrophysiol: 31 May 2023:e011143; epub ahead of print</small></div>

<div><h4>Pulsed Field Versus Cryoballoon Pulmonary Vein Isolation for Atrial Fibrillation: Efficacy, Safety, and Long-Term Follow-Up in a 400-Patient Cohort.</h4><i>Urbanek L, Bordignon S, Schaack D, Chen S, ... Schmidt B, Chun KRJ</i><br /><b>Background</b><br />The cryoballoon represents the gold standard single-shot device for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Single-shot pulsed field PVI ablation (nonthermal, cardiac tissue selective) has recently entered the arena. We sought to compare procedural data and long-term outcome of both techniques.<br /><b>Methods</b><br />Consecutive AF patients who underwent pulsed field ablation (PFA) and cryoballoon-based PVI were enrolled. Cryoballoon PVI was performed using the second-generation 28-mm cryoballoon; PFA was performed using a 31/35-mm pentaspline catheter. Success was defined as no recurrence of atrial tachyarrhythmia after a 3-month blanking period.<br /><b>Results</b><br />Four hundred patients were included (56.5% men; 60.8% paroxysmal AF; age, 70 [interquartile range, 59-77] years), 200 in each group (cryoballoon and PFA), and baseline characteristics did not differ. Acute PVI was achieved in 100% of PFA and in 98% (196/200) of cryoballoon patients (<i>P</i>=0.123; 4 touch-up ablations). Median procedure time was significantly shorter in PFA (34.5 [29-40] minutes) versus cryoballoon (50 [45-60] minutes; <i>P</i><0.001), fluoroscopy time was similar. Overall procedural complications were 6.5% in cryoballoon and 3.0% in PFA (<i>P</i>=0.1), driven by a higher rate of phrenic nerve palsies using cryoballoon. The 1-year success rates in paroxysmal AF (cryoballoon, 83.1%; PFA, 80.3%; <i>P</i>=0.724) and persistent AF (cryoballoon, 71%; PFA, 66.8%; <i>P</i>=0.629) were similar for both techniques.<br /><b>Conclusions</b><br />PFA compared with cryoballoon PVI shows a similar procedural efficacy but is associated with shorter procedure time and no phrenic nerve palsies. Importantly, 12-month clinical success rates are favorable but not different between both groups.<br /><br /><br /><br /><small>Circ Arrhythm Electrophysiol: 31 May 2023:e011920; epub ahead of print</small></div>

<div><h4>Procedure-Related Complications of Catheter Ablation for Atrial Fibrillation.</h4><i>Benali K, Khairy P, Hammache N, Petzl A, ... Andrade JG, Macle L</i><br /><b>Background</b><br />Catheter ablation of atrial fibrillation (AF) is a commonly performed procedure. However, it is associated with potentially significant complications. Reported procedure-related complication rates are highly variable, depending in part on study design.<br /><b>Objectives</b><br />The purpose of this systematic review and pooled analysis was to determine the rate of procedure-related complications associated with catheter ablation of AF using data from randomized control trials and to assess temporal trends.<br /><b>Methods</b><br />MEDLINE and EMBASE databases were searched from January 2013 to September 2022 for randomized control trials that included patients undergoing a first ablation procedure of AF using either radiofrequency or cryoballoon (PROSPERO, CRD42022370273).<br /><b>Results</b><br />A total of 1,468 references were retrieved, of which 89 studies met inclusion criteria. A total of 15,701 patients were included in the current analysis. Overall and severe procedure-related complication rates were 4.51% (95% CI: 3.76%-5.32%) and 2.44% (95% CI: 1.98%-2.93%), respectively. Vascular complications were the most frequent type of complication (1.31%). The next most common complications were pericardial effusion/tamponade (0.78%) and stroke/transient ischemic attack (0.17%). The procedure-related complication rate during the most recent 5-year period of publication was significantly lower than during the earlier 5-year period (3.77% vs 5.31%; P = 0.043). The pooled mortality rate was stable over the 2 time periods (0.06% vs 0.05%; P = 0.892). There was no significant difference in complication rate according to pattern of AF, ablation modality, or ablation strategies beyond pulmonary vein isolation.<br /><b>Conclusions</b><br />Procedure-related complications and mortality rates associated with catheter ablation of AF are low and have declined in the past decade.<br /><br />Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Am Coll Cardiol: 30 May 2023; 81:2089-2099</small></div>

<div><h4>Effect of prior anticoagulation therapy on stroke severity and in-hospital outcomes in patients with acute ischemic stroke and atrial fibrillation.</h4><i>Zhou L, Li Y, Yang X, Gu H, ... Wang C, Wang Y</i><br /><b>Background</b><br />We aimed to assess the prevalence of prior anticoagulation therapy (warfarin or non-vitamin K antagonist oral anticoagulants [NOACs]) among patients with acute ischemic stroke (AIS) and atrial fibrillation (AF) in China and investigate the associations between prior anticoagulation therapy and initial stroke severity and in-hospital outcomes.<br /><b>Methods</b><br />We included consecutive patients with AIS and known history of AF admitted to hospitals in the China Stroke Center Alliance (CSCA) program from January 2019 to July 2019. Multivariate logistic regression analyses were performed to determine the associations between prior anticoagulation therapy and initial stroke severity and in-hospital outcomes.<br /><b>Results</b><br />Of 7181 patients (median [IQR] age, 75.0 [68.0-81.0] years; 48.7% men), 700 (9.7%), 129 (1.8%), and 255 (3.6%) patients received prior subtherapeutic warfarin (international normalized ratio [INR] <2.0), therapeutic warfarin (INR ≥2.0), and NOACs therapy, respectively. A total of 6499 patients had a preadmission CHA<sub>2</sub>DS<sub>2</sub>-VASc score ≥ 2, among whom 94.6% were not adequately anticoagulated. Compared with no prior anticoagulation therapy, prior NOACs therapy was associated with reduced risk of moderate or severe stroke at admission (odds ratio [95% CI], 0.64 [0.43-0.94], P = 0.023) and in-hospital mortality or discharge against medical advice (DAMA) (0.46 [0.24-0.86], P = 0.015). However, no significant association was observed between prior therapeutic warfarin therapy and stroke severity or in-hospital mortality or DAMA.<br /><b>Conclusions</b><br />Among patients with AIS and AF in China, the proportion of patients with inadequate anticoagulation prior to stroke remained substantially high. Prior NOACs therapy was associated with reduced stroke severity and less in-hospital mortality or DAMA.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Int J Cardiol: 29 May 2023; epub ahead of print</small></div>

<div><h4>MACHINE LEARNING-POWERED, DEVICE-EMBEDDED HEART SOUND MEASUREMENT CAN OPTIMIZE AV DELAY IN CRT PATIENTS.</h4><i>Westphal P, Luo H, Shahmohammadi M, Prinzen FW, Delhaas T, Cornelussen RN</i><br /><b>Background</b><br />Continuous optimization of atrioventricular (AV)-delay for CRT is mainly performed by electrical means.<br /><b>Objective</b><br />Development of an estimation model of cardiac function that uses a piezoelectric microphone embedded in a pulse generator to guide CRT optimization.<br /><b>Methods</b><br />Electrocardiogram, left ventricular pressure (LVP) and heart sounds were simultaneously collected during CRT implantation procedures. A piezoelectric alarm-transducer embedded in a modified CRT device facilitated recording of heart sounds in patients undergoing a pacing protocol with different AV-delays. Machine-learning (ML) was employed to produce a decision-tree ensemble model capable of estimating absolute maximal LVP (LVP<sub>max</sub>) and maximal rise of LVP (LVdP/dt<sub>max</sub>) using 3 heart-sound-based features. To gauge the applicability of ML in AV-delay optimization, polynomial curves were fitted to measured and estimated values.<br /><b>Results</b><br />In the dataset of ∼30,000 heartbeats, ML indicated S1-, S2-amplitude and S1-integral (S1-energy for LVdP/dt<sub>max</sub>) as most prominent features for AV-delay optimization. ML resulted in single-beat estimation precision for absolute values of LVP<sub>max</sub> and LVdP/dt<sub>max</sub> of 67% and 64%, respectively. For 20-30 beat averages, cross-correlation between measured and estimated LVP<sub>max</sub> and LVdP/dt<sub>max</sub> was 0.999 for both. The estimated optimal AV-delays were not significantly different from those measured using invasive LVP (difference: -5.6±17.1 ms for LVP<sub>max</sub> and +5.1± 6.7 ms for LVdP/dt<sub>max</sub>). The difference in function at estimated and measured optimal AV delays was not statically significant (1±3mmHg for LVP<sub>max</sub> and 9±57mmHg/s for LVdP/dt<sub>max</sub>).<br /><b>Conclusion</b><br />Heart sound sensors embedded in a CRT device, powered by a ML-algorithm provide a reliable assessment of optimal AV-delays and absolute LVP<sub>max</sub> and LVdP/dt<sub>max</sub>.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 27 May 2023; epub ahead of print</small></div>

<div><h4>Relationship Between Endothelial Dysfunction and the Outcomes After Atrial Fibrillation Ablation.</h4><i>Okawa K, Sogo M, Morimoto T, Tsushima R, ... Ozaki M, Takahashi M</i><br /><AbstractText><br /><b>Background:</b><br/>Endothelial dysfunction (ED) is associated with cardiovascular events in patients with atrial fibrillation (AF). However, the utility of ED as a prognostic marker after AF ablation supplementary to the CHA<sub>2</sub>DS<sub>2</sub>-VASc score is unclear. This study aimed to investigate the relationship between ED and 5-year cardiovascular events in patients undergoing AF ablation. Methods and Results We conducted a prospective cohort study of patients who underwent a first-time AF ablation and for whom the endothelial function was assessed by the peripheral vascular reactive hyperemia index (RHI) before ablation. We defined ED as an RHI of <2.1. Cardiovascular events included strokes, heart failure requiring hospitalization, arteriosclerotic disease requiring treatment, venous thromboses, and ventricular arrhythmias or sudden cardiac death. We compared the 5-year incidence of cardiovascular events after AF ablation between those with and without ED. Among the 1040 patients who were enrolled, 829 (79.7%) had ED, and the RHI value was found to be associated with the CHA<sub>2</sub>DS<sub>2</sub>-VASc score (<i>P</i>=0.004). The 5-year incidence of cardiovascular events was higher among patients with ED than those without ED (98 [11.8%] versus 13 [6.2%]; log-rank <i>P</i>=0.014). We found ED to be an independent predictor of cardiovascular events after AF ablation (hazard ratio [HR], 1.91 [95% CI, 1.04-3.50]; <i>P</i>=0.036) along with a CHA<sub>2</sub>DS<sub>2</sub>-VASc score of ≥2 (≥3 for women) (HR, 3.68 [95% CI, 1.89-7.15]; <i>P</i><0.001). <br /><b>Conclusions:</b><br/>The prevalence of ED among patients with AF was high. Assessing the endothelial function could enable the risk stratification of cardiovascular events after AF ablation.</AbstractText><br /><br /><br /><br /><small>J Am Heart Assoc: 26 May 2023:e028482; epub ahead of print</small></div>

<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>Long-term safety and efficacy of renal sympathetic denervation in atrial fibrillation: 3-year results of the AFFORD study.</h4><i>Zeijen VJM, Theuns DA, Feyz L, Saville KA, ... Van Mieghem NM, Daemen J</i><br /><b>Background</b><br />Atrial fibrillation (AF) is the most common sustained arrhythmia which has been associated with increased sympathetic nervous system activity and hypertension. Recent evidence indicated that renal sympathetic denervation (RDN) could safely contribute to an improvement in AF burden.<br /><b>Objective</b><br />To investigate the long-term safety and efficacy of radiofrequency RDN in hypertensive patients with symptomatic AF.<br /><b>Methods</b><br />This pilot study included patients with symptomatic paroxysmal or persistent AF (European Hearth Rhythm Association class ≥ II) despite optimal medical therapy, office systolic blood pressure (BP) ≥ 140 mmHg and ≥ 2 antihypertensive drugs. AF burden was measured using an implantable cardiac monitor (ICM), implanted 3 months prior to RDN. ICM interrogation and 24-h ambulatory BP monitoring were performed at baseline and at 3/6/12/24/36 months post RDN. The primary efficacy outcome was daily AF burden. Statistical analyses were performed using Poisson and negative binomial models.<br /><b>Results</b><br />A total of 20 patients with a median age [25th-75th percentiles] of 66.2 [61.2-70.8] years (55% female) were included. At baseline, office BP ± standard deviation (SD) was 153.8/87.5 ± 15.2/10.4 mmHg, while mean 24-h ambulatory BP was 129.5/77.3 ± 15.5/9.3 mmHg. Baseline daily AF burden was 1.4 [0.0-10.9] minutes/day and throughout a 3-year follow-up period, no significant change was observed (- 15.4%/year; 95% confidence interval (CI) - 50.2%, + 43.7%; p = 0.54). The number of defined daily doses of antiarrhythmic drugs and antihypertensive drugs remained stable over time, while mean 24-h ambulatory systolic BP decreased with - 2.2 (95% CI - 3.9, - 0.6; p = 0.01) mmHg/year.<br /><b>Conclusions</b><br />In patients with hypertension and symptomatic AF, stand-alone RDN reduced BP but did not significantly reduce AF burden up until 3 years of follow-up.<br /><br />© 2023. The Author(s).<br /><br /><small>Clin Res Cardiol: 25 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>Early versus Later Anticoagulation for Stroke with Atrial Fibrillation.</h4><i>Fischer U, Koga M, Strbian D, Branca M, ... Dawson J, ELAN Investigators</i><br /><b>Background</b><br />The effect of early as compared with later initiation of direct oral anticoagulants (DOACs) in persons with atrial fibrillation who have had an acute ischemic stroke is unclear.<br /><b>Methods</b><br />We performed an investigator-initiated, open-label trial at 103 sites in 15 countries. Participants were randomly assigned in a 1:1 ratio to early anticoagulation (within 48 hours after a minor or moderate stroke or on day 6 or 7 after a major stroke) or later anticoagulation (day 3 or 4 after a minor stroke, day 6 or 7 after a moderate stroke, or day 12, 13, or 14 after a major stroke). Assessors were unaware of the trial-group assignments. The primary outcome was a composite of recurrent ischemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial hemorrhage, or vascular death within 30 days after randomization. Secondary outcomes included the components of the composite primary outcome at 30 and 90 days.<br /><b>Results</b><br />Of 2013 participants (37% with minor stroke, 40% with moderate stroke, and 23% with major stroke), 1006 were assigned to early anticoagulation and 1007 to later anticoagulation. A primary-outcome event occurred in 29 participants (2.9%) in the early-treatment group and 41 participants (4.1%) in the later-treatment group (risk difference, -1.18 percentage points; 95% confidence interval [CI], -2.84 to 0.47) by 30 days. Recurrent ischemic stroke occurred in 14 participants (1.4%) in the early-treatment group and 25 participants (2.5%) in the later-treatment group (odds ratio, 0.57; 95% CI, 0.29 to 1.07) by 30 days and in 18 participants (1.9%) and 30 participants (3.1%), respectively, by 90 days (odds ratio, 0.60; 95% CI, 0.33 to 1.06). Symptomatic intracranial hemorrhage occurred in 2 participants (0.2%) in both groups by 30 days.<br /><b>Conclusions</b><br />In this trial, the incidence of recurrent ischemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial hemorrhage, or vascular death at 30 days was estimated to range from 2.8 percentage points lower to 0.5 percentage points higher (based on the 95% confidence interval) with early than with later use of DOACs. (Funded by the Swiss National Science Foundation and others; ELAN ClinicalTrials.gov number, NCT03148457.).<br /><br />Copyright © 2023 Massachusetts Medical Society.<br /><br /><small>N Engl J Med: 24 May 2023; epub ahead of print</small></div>

<div><h4>Sodium-glucose cotransporter 2 inhibitor may not prevent atrial fibrillation in patients with heart failure: a systematic review.</h4><i>Ouyang X, Wang J, Chen Q, Peng L, Li S, Tang X</i><br /><b>Background</b><br />Atrial fibrillation (AF) and heart failure (HF) frequently coexist because of their similar pathological basis. However, whether sodium-glucose cotransporter 2 inhibitor (SGLT2i), a novel class of anti-HF medication, decreases the risk of AF in HF patients remains unclear.<br /><b>Objectives</b><br />The aim of this study was to assess the relationship between SGLT2i and AF in HF patients.<br /><b>Methods</b><br />A meta-analysis of randomized controlled trails evaluating the effects of SGLT2i on AF in HF patients was performed. PubMed and ClinicalTrails.gov were searched for eligible studies until 27 November 2022. The risk of bias and quality of evidence were assessed through the Cochrane tool. Pooled risk ratio of AF for SGLT2i versus placebo in eligible studies was calculated.<br /><b>Results</b><br />A total of 10 eligible RCTs examining 16,579 patients were included in the analysis. AF events occurred in 4.20% (348/8292) patients treated with SGLT2i, and in 4.57% (379/8287) patients treated with placebo. Meta-analysis showed that SGLT2i did not significantly reduce the risk of AF (RR 0.92; 95% CI 0.80-1.06; p = 0.23) in HF patients when compared to placebo. Similar results remained in the subgroup analyses, regardless of the type of SGLT2i, the type of HF, and the duration of follow-up.<br /><b>Conclusions</b><br />Current evidences showed that SGLT2i may have no preventive effects on the risk of AF in patients with HF.<br /><b>Translational perspective</b><br />Despite HF being one of the most common heart diseases and conferring increased risk for AF, affective prevention of AF in HF patients is still unresolved. The present meta-analysis demonstrated that SGLT2i may have no preventive effects on reducing AF in patients with HF. How to effectively prevent and early detect the occurrence of AF is worth discussing.<br /><br />© 2023. The Author(s).<br /><br /><small>Cardiovasc Diabetol: 24 May 2023; 22:124</small></div>

<div><h4>Subepicardial Cardiomyopathy: A Disease Underlying J-Wave Syndromes and Idiopathic Ventricular Fibrillation.</h4><i>Miles C, Boukens BJ, Scrocco C, Wilde AAM, ... Coronel R, Behr ER</i><br /><AbstractText>Brugada syndrome (BrS), early repolarization syndrome (ERS), and idiopathic ventricular fibrillation (iVF) have long been considered primary electrical disorders associated with malignant ventricular arrhythmia and sudden cardiac death. However, recent studies have revealed the presence of subtle microstructural abnormalities of the extracellular matrix in some cases of BrS, ERS, and iVF, particularly within right ventricular subepicardial myocardium. Substrate-based ablation within this region has been shown to ameliorate the electrocardiographic phenotype and to reduce arrhythmia frequency in BrS. Patients with ERS and iVF may also exhibit low-voltage and fractionated electrograms in the ventricular subepicardial myocardium, which can be treated with ablation. A significant proportion of patients with BrS and ERS, as well as some iVF survivors, harbor pathogenic variants in the voltage-gated sodium channel gene, <i>SCN5A</i>, but the majority of genetic susceptibility of these disorders is likely to be polygenic. Here, we postulate that BrS, ERS, and iVF may form part of a spectrum of subtle subepicardial cardiomyopathy. We propose that impaired sodium current, along with genetic and environmental susceptibility, precipitates a reduction in epicardial conduction reserve, facilitating current-to-load mismatch at sites of structural discontinuity, giving rise to electrocardiographic changes and the arrhythmogenic substrate.</AbstractText><br /><br /><br /><br /><small>Circulation: 23 May 2023; 147:1622-1633</small></div>

<div><h4>Risk for Bleeding-Related Hospitalizations During Use of Amiodarone With Apixaban or Rivaroxaban in Patients With Atrial Fibrillation : A Retrospective Cohort Study.</h4><i>Ray WA, Chung CP, Stein CM, Smalley W, ... Dickson AL, Murray KT</i><br /><b>Background</b><br />Amiodarone, the most effective antiarrhythmic drug in atrial fibrillation, inhibits apixaban and rivaroxaban elimination, thus possibly increasing anticoagulant-related risk for bleeding.<br /><b>Objective</b><br />For patients receiving apixaban or rivaroxaban, to compare risk for bleeding-related hospitalizations during treatment with amiodarone versus flecainide or sotalol, antiarrhythmic drugs that do not inhibit these anticoagulants\' elimination.<br /><b>Design</b><br />Retrospective cohort study.<br /><b>Setting</b><br />U.S. Medicare beneficiaries aged 65 years or older.<br /><b>Patients</b><br />Patients with atrial fibrillation began anticoagulant use between 1 January 2012 and 30 November 2018 and subsequently initiated treatment with study antiarrhythmic drugs.<br /><b>Measurements</b><br />Time to event for bleeding-related hospitalizations (primary outcome) and ischemic stroke, systemic embolism, and death with or without recent (past 30 days) evidence of bleeding (secondary outcomes), adjusted with propensity score overlap weighting.<br /><b>Results</b><br />There were 91 590 patients (mean age, 76.3 years; 52.5% female) initiating use of study anticoagulants and antiarrhythmic drugs, 54 977 with amiodarone and 36 613 with flecainide or sotalol. Risk for bleeding-related hospitalizations increased with amiodarone use (rate difference [RD], 17.5 events [95% CI, 12.0 to 23.0 events] per 1000 person-years; hazard ratio [HR], 1.44 [CI, 1.27 to 1.63]). Incidence of ischemic stroke or systemic embolism did not increase (RD, -2.1 events [CI, -4.7 to 0.4 events] per 1000 person-years; HR, 0.80 [CI, 0.62 to 1.03]). The risk for death with recent evidence of bleeding (RD, 9.1 events [CI, 5.8 to 12.3 events] per 1000 person-years; HR, 1.66 [CI, 1.35 to 2.03]) was greater than that for other deaths (RD, 5.6 events [CI, 0.5 to 10.6 events] per 1000 person-years; HR, 1.15 [CI, 1.00 to 1.31]) (HR comparison: <i>P</i> = 0.003). The increased incidence of bleeding-related hospitalizations for rivaroxaban (RD, 28.0 events [CI, 18.4 to 37.6 events] per 1000 person-years) was greater than that for apixaban (RD, 9.1 events [CI, 2.8 to 15.3 events] per 1000 person-years) (<i>P</i> = 0.001).<br /><b>Limitation</b><br />Possible residual confounding.<br /><b>Conclusion</b><br />In this retrospective cohort study, patients aged 65 years or older with atrial fibrillation treated with amiodarone during apixaban or rivaroxaban use had greater risk for bleeding-related hospitalizations than those treated with flecainide or sotalol.<br /><b>Primary funding source</b><br />National Heart, Lung, and Blood Institute.<br /><br /><br /><br /><small>Ann Intern Med: 23 May 2023; epub ahead of print</small></div>

<div><h4>Risk of serious hypoglycemia in patients with atrial fibrillation and diabetes concurrently taking antidiabetic drugs and oral anticoagulants: A nationwide cohort study.</h4><i>Huang HK, Liu PP, Lin SM, Yeh JI, ... Loh CH, Tu YK</i><br /><b>Aims</b><br />Evidence regarding the risks of serious hypoglycemia for patients with atrial fibrillation (AF) and diabetes mellitus (DM) taking antidiabetic medications with concurrent non-vitamin K antagonist oral anticoagulants (NOACs) versus warfarin is limited. This study aimed to investigate this knowledge gap.<br /><b>Methods and results</b><br />This retrospective cohort study used nationwide data from Taiwan\'s National Health Insurance Research Database and included a total of 56,774 adult patients treated with antidiabetic medications and oral anticoagulants between January 1, 2012 and December 31, 2020. The incidence rate ratios (IRRs) of serious hypoglycemia were estimated for patients taking antidiabetic drugs with NOACs versus warfarin. Poisson regression models with generalized estimating equations accounting for intra-individual correlation across follow-up periods were used. Stabilized inverse probability of treatment weighting was used to create treatment groups with balanced characteristics for comparisons. Compared to concurrent use of antidiabetic drugs with warfarin, those with NOACs showed a significantly lower risk of serious hypoglycemia (IRR = 0.73, 95% CI: 0.63-0.85, p<0.001). In the analyses of each NOAC, patients taking dabigatran (IRR = 0.76, 95% CI: 0.63-0.91, p = 0.002), rivaroxaban (IRR = 0.72, 95% CI: 0.61-0.86, p<0.001), and apixaban (IRR = 0.71, 95% CI: 0.57-0.89, p = 0.003) showed a significantly lower risk of serious hypoglycemia than those taking warfarin.<br /><b>Conclusion</b><br />In patients with AF and DM taking antidiabetic drugs, concurrent use of NOACs was associated with a lower risk of serious hypoglycemia than concurrent use of warfarin.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Pharmacother: 22 May 2023; epub ahead of print</small></div>

<div><h4>Catheter ablation of ventricular premature depolarizations originating from mid interventricular septum: Significance of electrocardiographic morphology for predicting origin.</h4><i>Liang Z, Zhang T, Liu L, Qi S, ... Wang Y, Ma C</i><br /><b>Background</b><br />Ventricular premature depolarizations (VPDs) originating from the mid interventricular septum (IVS) adjacent to the atrioventricular annulus between the His bundle and coronary sinus ostium (mid IVS VPDs) have not been characterized.<br /><b>Objective</b><br />The aim of this study was to investigate the electrophysiological characteristics of mid IVS VPDs.<br /><b>Methods</b><br />Thirty-eight patients with mid IVS VPDs were enrolled. The VPDs were divided into different types according to precordial transition of the electrocardiogram (ECG) and the QRS morphology in lead V1.<br /><b>Results</b><br />4 types of VPDs were divided. The precordial transition zone appeared earlier and earlier from types 1 to 4. The notch in V1 moved gradually backwards, its amplitude gradually became higher, resulting in transition from left to right bundle branch block morphology in V1 from types 1 to 4. Based on activation and pace mapping, ablation response, and the 3830 electrode pacing morphology in the mid IVS, the 4 types of ECG morphology corresponded, respectively, to an origin in the right endocardial side, right/mid intramural region, left intramural region, and left endocardial side of the mid IVS. An intramural origin was identified for 50% of the VPDs. 89% of mid IVS VPDs could be eliminated. Bilateral ablation (waiting for delayed efficacy) or bipolar ablation was sometimes needed for intramural VPDs.<br /><b>Conclusions</b><br />Mid IVS VPDs were found to have unique electrophysiological characteristics. The ECG characteristics of mid IVS VPDs was important in terms of prediction of its exact origin, the choice of ablation method, and the likelihood of treatment being successful.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 22 May 2023; epub ahead of print</small></div>

<div><h4>Effects of Stereotactic Arrhythmia Radioablation on left ventricular ejection fraction and valve function over time.</h4><i>van der Ree MH, Luca A, Siklody CH, Le Bloa M, ... Schiappacasse L, Pruvot E</i><br /><AbstractText>Twenty patients (80% male) were included, 15 (75%) with a non-ischemic cardiomyopathy. The radiotherapy dose was 20Gy (20;25) prescribed to a planning target volume (PTV) of 25cc (18;39) resulting in a median whole-heart dose of 6.1Gy. The follow-up duration before and after STAR was 2.1 (0.6;4.5) and 1.7 (0.9;3.9) years respectively. The number of echocardiograms was 5 (3;7) before and 4 (2;7) after STAR.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 22 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>2023 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Practical Management of the Remote Device Clinic.</h4><i>Ferrick AM, Raj SR, Deneke T, Kojodjojo P, ... Stühlinger M, Varosy PD</i><br /><AbstractText>Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.</AbstractText><br /><br />Published by Oxford University Press on behalf of the European Society of Cardiology 2023.<br /><br /><small>Europace: 19 May 2023; 25</small></div>

<div><h4>Effects of hyperbaric exposure on mechanical and electronic parameters of implantable cardioverter-defibrillators.</h4><i>Guenneugues R, Henckes A, Mansourati V, Mansourati J</i><br /><b>Aims</b><br />Hyperbaric oxygen therapy (HBOT) is the standard adjuvant treatment for life-threatening or disabling pathologies. Currently, mechanical and electronic variations of implantable cardioverter-defibrillators (ICD) in hyperbaric conditions have not been evaluated. As a result, many patients eligible for HBOT but ICD recipients cannot undergo this therapy, even in emergency situations.<br /><b>Methods and results</b><br />Twenty-two explanted ICD of various brands and models were randomized in two groups: single hyperbaric exposure at an absolute pressure of 4000 hPa and 30 iterative hyperbaric exposures at an absolute pressure of 4000 hPa. Mechanical and electronic parameters of these ICD were blindly assessed before, during, and after hyperbaric exposures. Regardless of the hyperbaric exposure, we could not find any mechanical distortion, inappropriate occurrence of anti-tachycardia therapies, dysfunction of tachyarrhythmia therapeutic programming, or dysfunction of programmed pacing parameters.<br /><b>Conclusion</b><br />Dry hyperbaric exposure seems harmless on ICD tested ex vivo. This result may lead to a reconsideration of the absolute contraindication of emergency HBOT to ICD recipients. A real-life study in these patients with an indication to HBOT should be performed to assess their tolerance to the treatment.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 19 May 2023; 25</small></div>

<div><h4>Association of atrial fibrillation and outcomes in patients undergoing bone marrow transplantation.</h4><i>Krishan S, Munir MB, Khan MZ, Al-Juhaishi T, ... Barac A, Asad ZUA</i><br /><b>Aims</b><br />Haematopoietic stem cell transplantation (HSCT) is a potentially curative therapy for several malignant and non-malignant haematologic conditions. Patients undergoing HSCT are at an increased risk of developing atrial fibrillation (AF). We hypothesized that a diagnosis of AF would be associated with poor outcomes in patients undergoing HSCT.<br /><b>Methods and results</b><br />The National Inpatient Sample (2016-19) was queried with ICD-10 codes to identify patients aged >50 years undergoing HSCT. Clinical outcomes were compared between patients with and without AF. A multivariable regression model adjusting for demographics and comorbidities was used to calculate the adjusted odds ratio (aOR) and regression coefficients with corresponding 95% confidence intervals and P-values. A total of 50 570 weighted hospitalizations for HSCT were identified, out of which 5820 (11.5%) had AF. Atrial fibrillation was found to be independently associated with higher inpatient mortality (aOR 2.75; 1.9-3.98; P < 0.001), cardiac arrest (aOR 2.86; 1.55-5.26; P = 0.001), acute kidney injury (aOR 1.89; 1.6-2.23; P < 0.001), acute heart failure exacerbation (aOR 5.01; 3.54-7.1; P < 0.001), cardiogenic shock (aOR 7.73; 3.17-18.8; P < 0.001), and acute respiratory failure (aOR 3.24; 2.56-4.1; P < 0.001) as well as higher mean length of stay (LOS) (+2.67; 1.79-3.55; P < 0.001) and cost of care (+67 529; 36 630-98 427; P < 0.001).<br /><b>Conclusion</b><br />Among patients undergoing HSCT, AF was independently associated with poor in-hospital outcomes, higher LOS, and cost of care.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 19 May 2023; 25</small></div>

<div><h4>Neutrophil-lymphocyte ratio and clinical outcomes in 19,697 patients with atrial fibrillation: Analyses from ENGAGE AF- TIMI 48 trial.</h4><i>Fagundes A, Ruff CT, Morrow DA, Murphy SA, ... Braunwald E, Giugliano RP</i><br /><b>Background</b><br />The neutrophil-to-lymphocyte ratio (NLR) is the ratio between neutrophil and lymphocyte counts measured in peripheral blood is easily calculable based on a routine blood test available worldwide and may reflect systemic inflammation. However, the relationship between NLR and clinical outcomes in atrial fibrillation (AF) patients is not well-described.<br /><b>Methods</b><br />We calculated NLR at baseline in ENGAGE AF-TIMI 48, a randomized trial comparing edoxaban versus warfarin in patients with AF followed for 2.8 years (median). The association of baseline NLR with major bleeding events, major adverse cardiac events (MACE), cardiovascular death, stroke/systemic embolism, and all-cause mortality were calculated.<br /><b>Results</b><br />The median baseline NLR in 19,697 patients was 2.53 (interquartile range 1.89-3.41). NLR was associated with major bleeding events (HR 1.60; 95% CI 1.41-1.80), stroke/systemic embolism (HR 1.25; 95% CI, 1.09-1.44), MI (HR 1.73; 95% CI 1.41-2.12), MACE (HR 1.70; 95% CI 1.56-1.84), CV (HR 1.93; 95% CI 1.74-2.13) and all-cause mortality (HR 2.00; 95% CI 1.83-2.18). The relationships between NLR and outcomes remained significant after adjustment for risk factors. Edoxaban consistently reduced major bleeding. MACE, and CV death across NLR groups vs. warfarin.<br /><b>Conclusions</b><br />NLR represents a widely available, simple, arithmetic calculation that could be immediately and automatically reported during a white blood cell differential measurement to identify patients with AF at increased risk of bleeding, CV events, and mortality.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Int J Cardiol: 19 May 2023; epub ahead of print</small></div>

<div><h4>Right ventricular function is a predictor for sustained ventricular tachycardia requiring anti-tachycardic pacing in arrhythmogenic ventricular cardiomyopathy: insight into transvenous vs. subcutaneous implantable cardioverter defibrillator insertion.</h4><i>Honarbakhsh S, Protonotarios A, Monkhouse C, Hunter RJ, Elliott PM, Lambiase PD</i><br /><b>Aims</b><br />Arrhythmogenic right ventricular cardiomyopathy (ARVC) patients develop ventricular arrhythmias (VAs) responsive to anti-tachycardia pacing (ATP). However, VA episodes have not been characterized in accordance with the device therapy, and with the emergence of the subcutaneous implantable cardioverter defibrillator (S-ICD), the appropriate device prescription in ARVC remains unclear. Study aim was to characterize VA events in ARVC patients during follow-up in accordance with device therapy and elicit if certain parameters are predictive of specific VA events.<br /><b>Methods and results</b><br />This was a retrospective single-centre study utilizing prospectively collated registry data of ARVC patients with ICDs. Forty-six patients were included [54.0 ± 12.1 years old and 20 (43.5%) secondary prevention devices]. During a follow-up of 12.1 ± 6.9 years, 31 (67.4%) patients had VA events [n = 2, 6.5% ventricular fibrillation (VF), n = 14], 45.2% VT falling in VF zone resulting in ICD shock(s), n = 10, 32.3% VT resulting in ATP, and n = 5, 16.1% patients had both VT resulting in ATP and ICD shock(s). Lead failure rates were high (11/46, 23.9%). ATP was successful in 34.5% of patients. Severely impaired right ventricular (RV) function was an independent predictor of VT resulting in ATP (hazard ratio 16.80, 95% confidence interval 3.74-75.2; P < 0.001) with a high predictive accuracy (area under the curve 0.88, 95%CI 0.76-1.00; P < 0.001).<br /><b>Conclusion</b><br />VA event rates are high in ARVC patients with a majority having VT falling in the VF zone resulting in ICD shock(s). S-ICDs could be of benefit in most patients with ARVC with the absence of severely impaired RV function which has the potential to avoid consequences of the high burden of lead failure.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 19 May 2023; 25</small></div>

<div><h4>Hybrid atrial fibrillation ablation: long-term outcomes from a single-centre 10-year experience.</h4><i>Pannone L, Mouram S, Della Rocca DG, Sorgente A, ... La Meir M, de Asmundis C</i><br /><b>Aims</b><br />Hybrid atrial fibrillation (AF) ablation is a promising approach in non-paroxysmal AF. The aim of this study is to assess the long-term outcomes of hybrid ablation in a large cohort of patients after both an initial and as a redo procedure.<br /><b>Methods and results</b><br />All consecutive patients undergoing hybrid AF ablation at UZ Brussel from 2010 to 2020 were retrospectively evaluated. Hybrid AF ablation was performed in a one-step procedure: (i) thoracoscopic ablation followed by (ii) endocardial mapping and eventual ablation. All patients received PVI and posterior wall isolation. Additional lesions were performed based on clinical indication and physician judgement. Primary endpoint was freedom from atrial tachyarrhythmias (ATas). A total of 120 consecutive patients were included, 85 patients (70.8%) underwent hybrid AF ablation as first procedure (non-paroxysmal AF 100%), 20 patients (16.7%) as second procedure (non-paroxysmal AF 30%), and 15 patients (12.5%) as third procedure (non-paroxysmal AF 33.3%). After a mean follow-up of 62.3 months ± 20.3, a total of 63 patients (52.5%) experienced ATas recurrence. Complications occurred in 12.5% of patients. There was no difference in ATas between patients undergoing hybrid as first vs. redo procedure (P = 0.53). Left atrial volume index and recurrence during blanking period were independent predictors of ATas recurrence.<br /><b>Conclusion</b><br />In a large cohort of patients undergoing hybrid AF ablation, the survival from ATas recurrence was 47.5% at ≈5 years follow-up. There was no difference in clinical outcomes between patients undergoing hybrid AF ablation as first procedure or as a redo.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 19 May 2023; 25</small></div>

<div><h4>Safety and Effectiveness of Pulsed Field Ablation to Treat Atrial Fibrillation: One-Year Outcomes From the MANIFEST-PF Registry.</h4><i>Turagam MK, Neuzil P, Schmidt B, Reichlin T, ... Rahe G, Reddy VY</i><br /><b>Background</b><br />Pulsed field ablation is a novel nonthermal cardiac ablation modality using ultra-rapid electrical pulses to cause cell death by a mechanism of irreversible electroporation. Unlike the traditional ablation energy sources, pulsed field ablation has demonstrated significant preferentiality to myocardial tissue ablation, and thus avoids certain thermally mediated complications. However, its safety and effectiveness remain unknown in usual clinical care.<br /><b>Methods</b><br />MANIFEST-PF (Multi-National Survey on the Methods, Efficacy, and Safety on the Post-Approval Clinical Use of Pulsed Field Ablation) is a retrospective, multinational, patient-level registry wherein patients at each center were prospectively included in their respective center registries. The registry included all patients undergoing postapproval treatment with a multielectrode 5-spline pulsed field ablation catheter to treat atrial fibrillation (AF) between March 1, 2021, and May 30, 2022. The primary effectiveness outcome was freedom from clinical documented atrial arrhythmia (AF/atrial flutter/atrial tachycardia) of ≥30 seconds on the basis of electrocardiographic data after a 3-month blanking period (on or off antiarrhythmic drugs). Safety outcomes included the composite of acute (<7 days postprocedure) and latent (>7 days) major adverse events.<br /><b>Results</b><br />At 24 European centers (77 operators) pulsed field ablation was performed in 1568 patients with AF: age 64.5±11.5 years, female 35%, paroxysmal/persistent AF 65%/32%, CHA<sub>2</sub>DS<sub>2</sub>-VASc 2.2±1.6, median left ventricular ejection fraction 60%, and left atrial diameter 42 mm. Pulmonary vein isolation was achieved in 99.2% of patients. After a median (interquartile range) follow-up of 367 (289-421) days, the 1-year Kaplan-Meier estimate for freedom from atrial arrhythmia was 78.1% (95% CI, 76.0%-80.0%); clinical effectiveness was more common in patients with paroxysmal AF versus persistent AF (81.6% versus 71.5%; <i>P</i>=0.001). Acute major adverse events occurred in 1.9% of patients.<br /><b>Conclusions</b><br />In this large observational registry of the postapproval clinical use of pulsed field technology to treat AF, catheter ablation using pulsed field energy was clinically effective in 78% of patients with AF.<br /><br /><br /><br /><small>Circulation: 18 May 2023; epub ahead of print</small></div>

<div><h4>U-shaped association between the triglyceride-glucose index and atrial fibrillation incidence in a general population without known cardiovascular disease.</h4><i>Liu X, Abudukeremu A, Jiang Y, Cao Z, ... Zhang Y, Wang J</i><br /><b>Objective</b><br />The triglyceride-glucose (TyG) index has been shown to be a new alternative measure for insulin resistance. However, no study has attempted to investigate the association of the TyG index with incident atrial fibrillation (AF) in the general population without known cardiovascular diseases.<br /><b>Methods</b><br />Individuals without known cardiovascular diseases (heart failure, coronary heart disease, or stroke) from the Atherosclerosis Risk in Communities (ARIC) cohort were recruited. The baseline TyG index was calculated as the Ln [fasting triglycerides (mg/dL) × fasting glucose (mg/dL)/2]. The association between the baseline TyG index and incident AF was examined using Cox regression.<br /><b>Results</b><br />Of 11,851 participants, the mean age was 54.0 years; 6586 (55.6%) were female. During a median follow-up of 24.26 years, 1925 incidents of AF cases (0.78/per 100 person-years) occurred. An increased AF incidence with a graded TyG index was found by Kaplan‒Meier curves (P < 0.001). In multivariable-adjusted analysis, both < 8.80 (adjusted hazard ratio [aHR] = 1.15, 95% confidence interval [CI] 1.02, 1.29) and > 9.20 levels (aHR 1.18, 95% CI 1.03, 1.37) of the TyG index were associated with an increased risk of AF compared with the middle TyG index category (8.80-9.20). The exposure-effect analysis confirmed the U-shaped association between the TyG index and AF incidence (P = 0.041). Further sex-specific analysis showed that a U-shaped association between the TyG index and incident AF still existed in females but not in males.<br /><b>Conclusions</b><br />A U-shaped association between the TyG index and AF incidence is observed in Americans without known cardiovascular diseases. Female sex may be a modifier in the association between the TyG index and AF incidence.<br /><br />© 2023. The Author(s).<br /><br /><small>Cardiovasc Diabetol: 18 May 2023; 22:118</small></div>

<div><h4>Machine Learning-Based Prediction of Atrial Fibrillation Risk Using Electronic Medical Records in Older Aged Patients.</h4><i>Kao YT, Huang CY, Fang YA, Liu JC, Chang TH</i><br /><AbstractText>Atrial fibrillation (AF) is an independent risk factor that increases the risk of stroke 5-fold. The purpose of our study was to develop a 1-year new-onset AF predictive model by machine learning based on 3-year medical information without electrocardiograms in our database to identify AF risk in older aged patients. We developed the predictive model according to the Taipei Medical University clinical research database electronic medical records, including diagnostic codes, medications, and laboratory data. Decision tree, support vector machine, logistic regression, and random forest algorithms were chosen for the analysis. A total of 2,138 participants (1,028 women [48.1%]; mean [standard deviation] age 78.8 [6.8] years) with AF and 8,552 random controls (after the matching process) without AF (4,112 women [48.1%]; mean [standard deviation] age 78.8 [6.8] years) were included in the model. The 1-year new-onset AF risk prediction model based on the random forest algorithm using medication and diagnostic information, along with specific laboratory data, attained an area under the receiver operating characteristic of 0.74, whereas the specificity was 98.7%. Machine learning-based model focusing on the older aged patients could offer acceptable discrimination in differentiating the risk of incident AF in the next year. In conclusion, a targeted screening approach using multidimensional informatics in the electronic medical records could result in a clinical choice with efficacy for prediction of the incident AF risk in older aged patients.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 18 May 2023; 198:56-63</small></div>

<div><h4>Optimizing diastolic filling by pacing in non-obstructive hypertrophic cardiomyopathy.</h4><i>Subramanian M, Shekar V, Krishnamurthy P, Yalagudri S, ... Chennapragada S, Narasimhan C</i><br /><b>Background</b><br />Treatment options for symptomatic patients with non-obstructive hypertrophic cardiomyopathy(nHCM) are limited.<br /><b>Objective</b><br />To determine the effect of sequential atrioventricular(AV) pacing, from different right ventricular(RV) sites with varying AV delays, on the diastolic function and functional capacity of patients with nHCM.<br /><b>Methods</b><br />Twenty-one patients with symptomatic nHCM and normal left ventricular systolic function were prospectively enrolled. Inclusion criteria included a PR interval>150ms, E/e\'>15 and an indication for ICD implantation. Doppler echocardiographic study was performed during dual chamber pacing at various AV intervals. Pacing was performed at three RV sites:RV apex(RVA),RV mid-septum(RVS),and RV outflow tract(RVO). The site and sensed AV delay(SAVD) at which optimal diastolic filling occurred was chosen based on diastolic filling period and E/e\'. During ICD implantation, the RV lead was implanted at the site identified by the pacing study. Devices were programmed in DDD mode at the optimal SAVD. During follow up, diastolic function and functional capacity were assessed.<br /><b>Results</b><br />Among the 21 patients(age 47.8+7.7yrs,males 81.0%), the baseline E/A and E/e\' were 2.4+0.6,and 17.2+2.2,respectively. There was an improvement in diastolic function (E/e\') in 18 patients(responders) when pacing from the RVA(12.9+3.4,p<0.001) compared to the RVS(16.6+2.3)and RVO(16.9+2.2). Among responders, optimal diastolic filling occurred at an SAVD of 130-160ms with RVA pacing. Non responders had longer duration of symptoms(p=0.006),lower LVEF(p=0.037),and higher LGE burden(p<0.001). During 13.5+1.5 months of follow up, there was an improvement(Δ)in diastolic function(E/e\'-4.1+0.5),functional capacity(NYHA-1.5+0.3),and reduction in NT-proBNP(-55.6+12.3pg/ml) compared to baseline.<br /><b>Conclusion</b><br />Pacing at an optimized AV delay from the RV apex improves diastolic function and functional capacity in a subset of patients with non-obstructive hypertrophic cardiomyopathy.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 18 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>Influence of Monitoring and Atrial Arrhythmia Burden on Quality of Life and Healthcare Utilization in Patients Undergoing Pulsed Field Ablation: A Secondary Analysis of the PULSED AF Trial.</h4><i>Verma A, Haines DE, Boersma LV, Sood N, ... DeLurgio DB, PULSED AF investigators</i><br /><b>Background</b><br />Freedom from atrial arrhythmia (AA) recurrence ≥30 seconds following pulsed field ablation (PFA) in patients with atrial fibrillation (AF) was reported in PULSED AF (NCT04198701). AA burden may be a more clinically meaningful endpoint.<br /><b>Objective</b><br />To determine the influence of monitoring strategies on AA detection and AA burden association with quality of life (QoL) and healthcare utilization (HCU) following PFA.<br /><b>Methods</b><br />Patients underwent 24-hour Holter at 6 and 12 months and weekly and symptomatic trans-telephonic monitoring (TTM). AA burden post-blanking was calculated as the greater of 1) percentage of AA on total Holter time, or 2) percentage of weeks with ≥1 TTM with AA out of all weeks with ≥1 TTM.<br /><b>Results</b><br />Freedom from all AAs varied >20% when differing monitoring strategies were employed. PFA resulted in zero burden in 69.4% of paroxysmal (PAF) and 62.2% of persistent (PsAF) AF patients; median burden was low (<9%). Most PAF and PsAF patients had ≤1 week of AA detection on TTM (82.6% and 75.4%) and <30 minutes of AA per day of Holter monitoring (96.5% and 89.6%), respectively. Only PAF patients with <10% AA burden averaged a clinically meaningful (>19 point) QoL improvement. PsAF patients experienced clinically meaningful QoL improvements irrespective of burden. Repeat ablations and cardioversions significantly increased with higher AA burden (p<0.01).<br /><b>Conclusion</b><br />The ≥30-second AA endpoint is dependent on the monitoring protocol utilized. PFA resulted in low AA burden for most patients, which was associated with clinically relevant improvement in QoL and reduced AA-related HCU.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 17 May 2023; epub ahead of print</small></div>

<div><h4>MAgnetic resonance imaging based DUal lead cardiac Resynchronization therapy: A prospectIve Left Bundle Branch Pacing Study (MADURAI LBBP study).</h4><i>Ponnusamy SS, Ganesan V, Ramalingam V, Syed T, ... Murugan M, Vijayaraman P</i><br /><b>Background</b><br />Cardiac resynchronization therapy(CRT) is a class-I indication for LVEF≤35%, and heart failure(HF). LBBB associated nonischemic-cardiomyopathy (LB-NICM) with minimal or no scar by cardiac-magnetic-resonance(CMR) imaging may be associated with excellent prognosis following CRT. Left-bundle-branch-pacing(LBBP) can achieve excellent resynchronization in LBBB patients.<br /><b>Objectives</b><br />Aim of our study was to prospectively assess feasibility and efficacy of LBBP with or without a defibrillator in patients with LB-NICM and LVEF ≤35%, risk stratified by CMR.<br /><b>Methods</b><br />Pts with LB-NICM, LVEF≤35% and HF were prospectively enrolled from 2019 to 2022. If the scar burden<10% by CMR, LBBP only (Group-I) and if ≥10%, LBBP+ICD(Group-II) was performed. Primary endpoints-1.Echocardiographic-response(ER)- ΔLVEF ≥15% at 6 months; 2.Composite of time to death, HFH or sustained VT/VF. Secondary endpoints-1.Echocardiographic-hyper-response(EHR-LVEF≥50%orΔLVEF ≥20%) at 6 and 12 months; 2.Indication for ICD-upgradation(persistent LVEF<35% at 12 months or sustained VT/VF) <br /><b>Results:</b><br/>120 patients were enrolled. CMR showed <10% scar-burden in 109 patients(90.8%). 4 patients opted for LBBP+ICD and withdrew. LBBP optimized-dual-chamber-pacemaker(LOT-DDD-P) was done in 101 patients and LOT-CRT-P in 4 patients(Group-I,n=105). Scar-burden ≥10% in 11 pts who underwent LBBP+ICD(Group-II). During mean-follow-up 21±12 months, primary endpoint of ER observed in 80%(68/85 pts) in Group-I vs 27%(3/11 pts) in Group-II(p-0.0001). Primary composite-endpoint of death,HFH or VT/VF occurred in 3.8% in group-I vs 33.3% in Group-II(p<0.0001). Secondary endpoint of EHR(LVEF≥50%) observed in 39.5%vs0%, 61.2%vs9.1% and 80%vs33.3% at 3, 6 and 12 months in group-I and group-II respectively.<br /><b>Conclusion</b><br />CMR guided CRT using LOT-DDD-P appears to be a safe and feasible approach in LB-NICM and has the potential to reduce healthcare cost.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 17 May 2023; epub ahead of print</small></div>

<div><h4>Sodium-Glucose Cotransporter-2 Inhibitor Prevents Stroke in Patients With Diabetes and Atrial Fibrillation.</h4><i>Chang SN, Chen JJ, Huang PS, Wu CK, ... Hwang JJ, Tsai CT</i><br /><AbstractText><br /><b>Background:</b><br/>Atrial fibrillation (AF) is associated with increasing risk of thromboembolic or ischemic stroke. The CHA<sub>2</sub>DS<sub>2</sub>-VASc score is a well-established predictor of AF stroke. Patients with AF have an increased risk of stroke if they have diabetes. Use of sodium-glucose cotransporter-2 inhibitor (SGLT2i) has been shown to be associated with favorable cardiovascular outcomes in patients with diabetes. It was unknown whether use of SGLT2i decreased stroke risk in patients with AF who have diabetes. Methods and Results A total of 9116 patients with AF and diabetes from the National Taiwan University historical cohort were longitudinally followed up for 5 years (January 2016-December 2020). The risk of stroke related to SGLT2i use was evaluated by Cox model, adjusting CHA<sub>2</sub>DS<sub>2</sub>-VASc score in the propensity score-matched population with 474 SGLT2i users and 3235 nonusers. Adverse thromboembolic end points during follow-up were defined as ischemic stroke. The mean age was 73.2±10.5 years, and 61% of patients were men. There were no significant differences of baseline characteristics between users and nonusers of SGLT2i, including CHA<sub>2</sub>DS<sub>2</sub>-VASc score in the propensity score-matched population. The stroke rate was 3.4% (95% CI, 2.8-4.2) patient-years in SGLT2i users and 4.3% (95% CI, 4.0-4.6) in nonusers (<i>P</i>=0.021). SGLT2i users had a 20% reduction of stroke (hazard ratio, 0.80 [95% CI, 0.64-0.99]; <i>P</i>=0.043) after adjustment for the CHA<sub>2</sub>DS<sub>2</sub>-VASc score. <br /><b>Conclusions:</b><br/>Use of SGLT2i was associated with a lower stroke risk in patients with diabetes and AF, and it may be considered to escalate SGLT2i to the first-line treatment in patients with diabetes and AF.</AbstractText><br /><br /><br /><br /><small>J Am Heart Assoc: 16 May 2023; 12:e027764</small></div>

<div><h4>Prevalence and Impact of Poorly Controlled Modifiable Risk Factors Among Patients Who Underwent Atrial Fibrillation Ablation.</h4><i>Stout K, Almerstani M, Adomako R, Shin D, ... Peeraphatdit T, Naksuk N</i><br /><AbstractText>Managing atrial fibrillation (AF) risk factors (RFs) improves ablation outcomes in obese patients. However, real-world data, including nonobese patients, are limited. This study examined the modifiable RFs of consecutive patients who underwent AF ablation at a tertiary care hospital from 2012 to 2019. The prespecified RFs included body mass index (BMI) ≥30 kg/m<sup>2</sup>, >5% fluctuation in BMI, obstructive sleep apnea with continuous positive airway pressure noncompliance, uncontrolled hypertension, uncontrolled diabetes, uncontrolled hyperlipidemia, tobacco use, alcohol use higher than the standard recommendation, and a diagnosis-to-ablation time (DAT) >1.5 years. The primary outcome was a composite of arrhythmia recurrence, cardiovascular admissions, and cardiovascular death. In this study, a high prevalence of preablation modifiable RFs was observed. More than 50% of the 724 study patients had uncontrolled hyperlipidemia, a BMI ≥30 mg/m<sup>2</sup>, a fluctuating BMI >5%, or a delayed DAT. During a median follow-up of 2.6 (interquartile range 1.4 to 4.6) years, 467 patients (64.5%) met the primary outcome. Independent RFs were a fluctuation in BMI >5% (hazard ratio [HR] 1.31, p = 0.008), diabetes with A<sub>1c</sub> ≥6.5% (HR 1.50, p = 0.014), and uncontrolled hyperlipidemia (HR 1.30, p = 0.005). A total of 264 patients (36.46%) had at least 2 of these predictive RFs, which was associated with a higher incidence of the primary outcome. Delayed DAT over 1.5 years did not alter the ablation outcome. In conclusion, substantial portions of patients who underwent AF ablation have potentially modifiable RFs that were not well controlled. Fluctuating BMI, diabetes with hemoglobin A<sub>1c</sub> ≥6.5%, and uncontrolled hyperlipidemia portend an increased risk of recurrent arrhythmia, cardiovascular hospitalizations, and mortality after ablation.</AbstractText><br /><br />Published by Elsevier Inc.<br /><br /><small>Am J Cardiol: 16 May 2023; 198:38-46</small></div>

<div><h4>2023 HRS Expert Consensus Statement on the Management of Arrhythmias During Pregnancy.</h4><i>Joglar JA, Kapa S, Saarel EV, Dubin AM, ... Zelop CM, Zentner D</i><br /><AbstractText>This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 16 May 2023; epub ahead of print</small></div>

<div><h4>Atrial Fibrillation Ablation in Young Adults: Measuring Quality of Life Using Patient-Reported Outcomes Over 5 Years.</h4><i>Johnson BM, Wazni OM, Farwati M, Saliba WI, ... Nakagawa H, Hussein AA</i><br /><b>Background</b><br />Ablation is used for both rhythm control and improved quality of life (QoL) in atrial fibrillation (AF). It has been suggested that young adults may experience high recurrence rates after ablation and data remain lacking regarding QoL benefits. We aimed to investigate AF ablation outcomes and QoL benefits in young adults undergoing AF ablation using a large prospectively maintained registry and automated patient-reported outcomes (PRO).<br /><b>Methods</b><br />All patients undergoing AF ablation (2013-2016) at our center were prospectively enrolled. Patients aged 50 years or younger were included. For PROs, QoL measures and symptoms were assessed at baseline, 3 months after ablation, and every 6 months thereafter. The AF severity score served as the main assessment of QoL.<br /><b>Results</b><br />A total of 241 young adults (age, 16-50 years) were included (17% female, 40.3% persistent AF). In all, 77.2% of patients remained arrhythmia-free during the first year of follow-up (80% in nonstructural AF and 66% in structural AF). Using PROs, 90% of patients reported improvement in QoL throughout all survey time points up to 5 years postablation (<i>P</i><0.0001). The baseline median AF severity score was 14 and improved to between 2 and 4 on all follow-up after ablation (<i>P</i><0.0001). Patients also reported fewer and shorter AF episodes, fewer emergency room visits secondary to AF, and fewer hospitalizations (<i>P</i><0.0001).<br /><b>Conclusions</b><br />Ablation remains an effective rhythm-control strategy in young adults with AF. Young adults also experience significant improvement in QoL with reduction of the frequency and duration of AF episodes and AF-related healthcare utilization.<br /><br /><br /><br /><small>Circ Arrhythm Electrophysiol: 15 May 2023:e011565; epub ahead of print</small></div>

<div><h4>Early Impact of Proton Beam Therapy on Electrophysiological Characteristics in a Porcine Model.</h4><i>Imamura K, Deisher AJ, Dickow J, Rettmann ME, ... Foote RL, Packer DL</i><br /><b>Background</b><br />Particle therapy is a noninvasive, catheter-free modality for cardiac ablation. We previously demonstrated the efficacy for creating ablation lesions in the porcine heart. Despite several earlier studies, the exact mechanism of early biophysical effects of proton and photon beam delivery on the myocardium remain incompletely resolved.<br /><b>Methods</b><br />Ten normal and 9 infarcted in situ porcine hearts received proton beam irradiation (40 Gy) delivered to the left ventricular myocardium with follow-up for 8 weeks. High-resolution electroanatomical mapping of the left ventricular was performed at baseline and follow-up. Bipolar voltage amplitude, conduction velocity, and connexin-43 were determined within the irradiated and nonirradiated areas.<br /><b>Results</b><br />The irradiated area in normal hearts showed a significant reduction of bipolar voltage amplitude (10.1±4.9 mV versus 5.7±3.2, <i>P</i><0.0001) and conduction velocity (85±26 versus 55±13 cm/s, <i>P</i>=0.03) beginning at 4 weeks after irradiation. In infarcted myocardium after irradiation, bipolar voltage amplitude of the infarct scar (2.0±2.9 versus 0.8±0.7 mV, <i>P</i>=0.008) was significantly reduced as well as the conduction velocity in the infarcted heart (43.7±15.7 versus 26.3±11.4 cm/s, <i>P</i>=0.02). There were no significant changes in bipolar voltage amplitude and conduction velocity in nonirradiated myocardium. Myocytolysis, capillary hyperplasia, and dilation were seen in the irradiated myocardium 8 weeks after irradiation. Active caspase-3 and reduction of connexin-43 expression began in irradiated myocardium 1 week after irradiation and decreased over 8 weeks.<br /><b>Conclusions</b><br />Irradiation of the myocardium with proton beams reduce connexin-43 expression, conduction velocity, and bipolar conducted electrogram amplitude in a large porcine model. The changes in biomarkers preceded electrophysiological changes after proton beam therapy.<br /><br /><br /><br /><small>Circ Arrhythm Electrophysiol: 15 May 2023:e011179; epub ahead of print</small></div>

<div><h4>Effects of Atrioventricular Optimization on Left Ventricular Reverse Remodeling With Cardiac Resynchronization Therapy: Results of the SMART-CRT Trial.</h4><i>Gold MR, Ellenbogen K, Leclercq C, Lowy J, ... Stein KM, Auricchio A</i><br /><b>Background</b><br />The role of atrioventricular optimization (AVO) to improve cardiac resynchronization therapy outcomes remains controversial. Previous post hoc analyses of a multicenter trial showed that measures of electrical dyssynchrony (right ventricular-left ventricular [LV] or QLV durations) are associated with patients who benefit from AVO.<br /><b>Methods</b><br />This was a global, multicenter, prospective, randomized trial of de novo cardiac resynchronization therapy implant patients with an right ventricular-LV duration ≥70 ms to determine whether AVO results in greater reverse remodeling. Patients were randomized 1:1 for either an AVO algorithm (SmartDelay) that determines atrioventricular delay and pacing chamber, biventricular or LV only, or a fixed atrioventricular delay of 120 ms with biventricular pacing. Paired echocardiograms performed at baseline and 6 months were evaluated. The primary end point was echocardiographic cardiac resynchronization therapy response, defined dichotomously as a >15% reduction in LV end-systolic volume.<br /><b>Results</b><br />A total of 310 patients (n=120 women) were randomized and had completed 6 months of follow-up. The echocardiographic cardiac resynchronization therapy response rate did not statistically differ between the groups (SmartDelay, 74.8%; fixed, 67.7%; <i>P</i>=0.17). Analyses of prespecified secondary end points demonstrated significant improvements in the absolute (median: SmartDelay, -41.0 mL; fixed, -33.0 mL; <i>P</i>=0.01) and relative change in LV end-systolic volume (SmartDelay, -38.3%; fixed, -27.8%; <i>P</i>=0.03) for patients with SmartDelay optimization. Similar results were observed for the relative improvement in LV ejection fraction (SmartDelay, 46.7%; fixed, 32.1%; <i>P</i>=0.050); absolute improvement in LV ejection fraction trended to be higher with SmartDelay (<i>P</i>=0.06).<br /><b>Conclusions</b><br />Analysis of reverse remodeling parameters demonstrated that AVO via SmartDelay, relative to the nonoptimized fixed atrioventricular delay comparator group, improved absolute and relative changes in LV function in patients with longer right ventricular-LV duration.<br /><b>Registration</b><br />URL: https://www.<br /><b>Clinicaltrials</b><br />gov; Unique identifier: NCT03089281.<br /><br /><br /><br /><small>Circ Arrhythm Electrophysiol: 15 May 2023:e011714; epub ahead of print</small></div>

<div><h4>In-hospital complications associated with pulmonary vein isolation with adjunctive lesions: the NCDR AFib Ablation Registry.</h4><i>Darden D, Aldaas O, Du C, Munir MB, ... Akar JG, Hsu JC</i><br /><b>Aims</b><br />No prior study has been adequately powered to evaluate real-world safety outcomes in those receiving adjunctive ablation lesions beyond pulmonary vein isolation (PVI). We sought to evaluate characteristics and in-hospital complications among patients undergoing PVI with and without adjunctive lesions.<br /><b>Methods and results</b><br />Patients in the National Cardiovascular Data Registry AFib Ablation Registry undergoing first-time atrial fibrillation (AF) ablation between 2016 and 2020 were identified and stratified into paroxysmal (PAF) and persistent AF, and separated into PVI only, PVI + cavotricuspid isthmus (CTI) ablation, and PVI + adjunctive (superior vena cava isolation, coronary sinus, vein of Marshall, atypical atrial flutter lines, other). Adjusted odds of adverse events were calculated using multivariable logistic regression. A total of 50 937 patients [PAF: 30 551 (60%), persistent AF: 20 386 (40%)] were included. Among those with PAF, there were no differences in the adjusted odds of complications between PVI + CTI or PVI + adjunctive when compared with PVI only. Among persistent AF, PVI + adjunctive was associated with a higher risk of any complication [3.0 vs. 4.5%, odds ratio (OR) 1.30, 95% confidence interval (CI) 1.07-1.58] and major complication (0.8 vs. 1.4%, OR 1.56, 95% CI 1.10-2.21), while no differences were observed in PVI + CTI compared with PVI only. Overall, there was high heterogeneity in adjunctive lesion type, and those receiving adjunctive lesions had a higher comorbidity burden.<br /><b>Conclusion</b><br />Additional CTI ablation was common without an increased risk of complications. Adjunctive lesions other than CTI are commonly performed in those with more comorbidities and were associated with an increased risk of complications in persistent AF, although the current analysis is limited by high heterogeneity in adjunctive lesion set type.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 15 May 2023; epub ahead of print</small></div>

<div><h4>Reduced Left Atrial Appendage Flow Is Associated With Future Atrial Fibrillation After Cryptogenic Stroke.</h4><i>Dhont S, Wouters F, Deferm S, Bekelaar K, ... Vandervoort P, Bertrand PB</i><br /><b>Background</b><br />Hemostasis within the left atrial appendage (LAA) is a common cause of stroke, especially in patients with atrial fibrillation (AF). Although LAA flow provides insights into LAA function, its potential for predicting AF has yet to be established. The aim of this study was to explore whether LAA peak flow velocities early after cryptogenic stroke are associated with future AF on prolonged rhythm monitoring.<br /><b>Methods</b><br />A total of 110 patients with cryptogenic stroke were consecutively enrolled and underwent LAA pulsed-wave Doppler flow assessment using transesophageal echocardiography within the early poststroke period. Velocity measurements were analyzed offline by an investigator blinded to the results. Prolonged rhythm monitoring was conducted on all participants via 7-day Holter and implantable cardiac monitoring devices, with follow-up conducted over a period of 1.5 years to determine the incidence of AF. The end point of AF was defined as irregular supraventricular rhythm with variable RR interval and no detectable P waves lasting ≥30 sec during rhythm monitoring.<br /><b>Results</b><br />During a median follow-up period of 539 days (interquartile range, 169-857 days), 42 patients (38%) developed AF, with a median time to AF diagnosis of 94 days (interquartile range, 51-487 days). Both LAA filling velocity and LAA emptying velocity (LAAev) were lower in patients with AF (44.3 ± 14.2 and 50.7 ± 13.3 cm/s, respectively) compared with patients without AF (59.8 ± 14.0 and 76.8 ± 17.3 cm/sec, respectively; P < .001 for both). LAAev was most strongly associated with future AF, with an area under the receiver operating characteristic curve of 0.88 and an optimal cutoff value of 55 cm/sec. Age and mitral regurgitation were independent determinants of reduced LAAev.<br /><b>Conclusions</b><br />Impaired LAA peak flow velocities (LAAev < 55 cm/sec) in patients with cryptogenic stroke are associated with future AF. This may facilitate the selection of appropriate candidates for prolonged rhythm monitoring to improve its diagnostic accuracy and implementation.<br /><br />Copyright © 2023 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Am Soc Echocardiogr: 15 May 2023; epub ahead of print</small></div>

<div><h4>Catheter ablation of atrial fibrillation and atrial tachycardia in patients with pulmonary hypertension: a randomized study.</h4><i>Havranek S, Fingrova Z, Skala T, Reichenbach A, ... Linhart A, Wichterle D</i><br /><b>Aims</b><br />Atrial fibrillation (AF), typical atrial flutter (AFL), and other atrial tachycardias (ATs) are common in patients with pulmonary hypertension. Frequently, several supraventricular arrhythmias are successively observed in individual patients. We investigated the hypothesis of whether more extensive radiofrequency catheter ablation of the bi-atrial arrhythmogenic substrate instead of clinical arrhythmia ablation alone results in superior clinical outcomes in patients with pulmonary arterial hypertension (PH) and supraventricular arrhythmias.<br /><b>Methods and results</b><br />Patients with combined post- and pre-capillary or isolated pre-capillary PH and supraventricular arrhythmia indicated to catheter ablation were enrolled in three centres and randomized 1:1 into two parallel treatment arms. Patients underwent either clinical arrhythmia ablation only (Limited ablation group) or clinical arrhythmia plus substrate-based ablation (Extended ablation group). The primary endpoint was arrhythmia recurrence >30 s without antiarrhythmic drugs after the 3-month blanking period. A total of 77 patients (mean age 67 ± 10 years; 41 males) were enrolled. The presumable clinical arrhythmia was AF in 38 and AT in 36 patients, including typical AFL in 23 patients. During the median follow-up period of 13 (interquartile range: 12; 19) months, the primary endpoint occurred in 15 patients (42%) vs. 17 patients (45%) in the Extended vs. Limited ablation group (hazard ratio: 0.97, 95% confidence interval: 0.49-2.0). There was no excess of procedural complications and clinical follow-up events including an all-cause death in the Extended ablation group.<br /><b>Conclusion</b><br />Extensive ablation, compared with a limited approach, was not beneficial in terms of arrhythmia recurrence in patients with AF/AT and PH.<br /><b>Clinical trials registration</b><br />ClinicalTrials.gov; NCT04053361.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 13 May 2023; epub ahead of print</small></div>

<div><h4>Systematic Electrophysiological Study Prior to Pulmonary Valve Replacement in Tetralogy of Fallot: A Prospective Multicenter Study.</h4><i>Waldmann V, Bessière F, Gardey K, Bakloul M, ... Khairy P, Combes N</i><br /><b>Background</b><br />Ventricular arrhythmias and sudden death are recognized complications in tetralogy of Fallot. Electrophysiological studies (EPS) before pulmonary valve replacement (PVR), the most common reintervention in tetralogy of Fallot, could potentially inform therapy to improve arrhythmic outcomes.<br /><b>Methods</b><br />A prospective multicenter study was conducted to systematically assess EPS with programmed ventricular stimulation in patients with tetralogy of Fallot referred for PVR from January 2020 to December 2021. A standardized stimulation protocol was used across all centers.<br /><b>Results</b><br />A total of 120 patients were enrolled, mean age 39.2±14.5 years, 53.3% males. Sustained ventricular tachycardia was induced in 27 (22.5%) patients. When identifiable, the critical isthmus most commonly implicated (ie, in 90.0%) was between the ventricular septal defect patch and pulmonary annulus. Factors independently associated with inducible ventricular tachycardia were history of atrial arrhythmia (OR, 8.56 [95% CI, 2.43-34.73]) and pulmonary annulus diameter >26 mm (OR, 5.05 [95% CI, 1.47-21.69]). The EPS led to a substantial change in management in 23 (19.2%) cases: 18 (15.0%) had catheter ablation, 3 (2.5%) surgical cryoablation during PVR, and 9 (7.5%) defibrillator implantation. Repeat EPS 5.1 (4.8-6.2) months after PVR was negative in 8 of 9 (88.9%) patients. No patient experienced a sustained ventricular arrhythmia during 13 (6.1-20.1) months of follow-up.<br /><b>Conclusions</b><br />Systematically performing programmed ventricular stimulation in patients with tetralogy of Fallot referred for PVR yields a high rate of inducible ventricular tachycardia and carries the potential to alter management. It remains to be determined whether a standardized treatment approach based on the results of EPS will translate into improved outcomes.<br /><b>Registration</b><br />URL: https://www.<br /><b>Clinicaltrials</b><br />gov; Unique identifier: NCT04205461.<br /><br /><br /><br /><small>Circ Arrhythm Electrophysiol: 12 May 2023:e011745; epub ahead of print</small></div>

<div><h4>Relative Contribution of Atrial Fibrillation to Outcomes of Patients With Cardiomyopathy Based on Severity of Left Ventricular Dysfunction.</h4><i>Ayub MT, Rangavajla G, Thoma F, Mulukutla S, ... Jain S, Saba S</i><br /><AbstractText>In patients with left ventricular (LV) dysfunction, the risk of death or heart failure hospitalizations (HFHs) increases with worsening ejection fraction (EF). Whether the relative contribution of atrial fibrillation (AF) to outcomes is more pronounced in patients with worse EF is not confirmed. The present study aimed to investigate the relative influence of AF on the outcome of cardiomyopathy patients by severity of LV dysfunction. In this observational study, data from 18,003 patients with EF ≤50% seen at a large academic institution between 2011 and 2017 were analyzed. Patients were stratified by EF quartiles (EF<25%, 25%≤EF<35%, 35%≤EF<40%, and EF≥40%, for quartiles 1, 2, 3, and 4, respectively). and followed to the end point of death or HFH. Outcomes of AF versus non-AF patients were compared within each EF quartile. During a median follow-up of 3.35 years, 8,037 patients (45%) died and 7,271 (40%) had at least 1 HFH. Rates of HFH and all-cause mortality increased as EF decreased. The hazard ratios (HRs) of death or HFH for AF versus non-AF patients increased steadily with increasing EF (HR of 1.22, 1.27, 1.45, 1.50 for quartiles 1, 2, 3, and 4, respectively, p = 0.045) driven primarily by the risk of HFH (HR of 1.26, 1.45, 1.59, 1.69 for quartiles 1, 2, 3, and 4, respectively, p = 0.045). In conclusion, in patients with LV dysfunction, the detrimental influence of AF on the risk of HFH is more pronounced in those with more preserved EF. Mitigation strategies for AF with the goal of decreasing HFH may be more impactful in patients with more preserved LV function.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 12 May 2023; 198:9-13</small></div>

<div><h4>Atrial substrate characterization based on bipolar voltage electrograms acquired with multipolar, focal and mini-electrode catheters.</h4><i>Knecht S, Schlageter V, Badertscher P, Krisai P, ... Sticherling C, Kühne M</i><br /><b>Background</b><br />Bipolar voltage (BV) electrograms for left atrial (LA) substrate characterization depend on catheter design and electrode configuration.<br /><b>Aims</b><br />The aim of the study was to investigate the relationship between the BV amplitude (BVA) using four catheters with different electrode design and to identify their specific LA cutoffs for scar and healthy tissue.<br /><b>Methods and results</b><br />Consecutive high-resolution electroanatomic mapping was performed using a multipolar-minielectrode Orion catheter (Orion-map), a duo-decapolar circular mapping catheter (Lasso-map), and an irrigated focal ablation catheter with minielectrodes (Mifi-map). Virtual remapping using the Mifi-map was performed with a 4.5 mm tip-size electrode configuration (Nav-map). BVAs were compared in voxels of 3 × 3 × 3 mm3. The equivalent BVA cutoff for every catheter was calculated for established reference cutoff values of 0.1, 0.2, 0.5, 1.0, and 1.5 mV. We analyzed 25 patients (72% men, age 68 ± 15 years). For scar tissue, a 0.5 mV cutoff using the Nav corresponds to a lower cutoff of 0.35 mV for the Orion and of 0.48 mV for the Lasso. Accordingly, a 0.2 mV cutoff corresponds to a cutoff of 0.09 mV for the Orion and of 0.14 mV for the Lasso. For healthy tissue cutoff at 1.5 mV, a larger BVA cutoff for the small electrodes of the Orion and the Lasso was determined of 1.68 and 2.21 mV, respectively.<br /><b>Conclusion</b><br />When measuring LA BVA, significant differences were seen between focal, multielectrode, and minielectrode catheters. Adapted cutoffs for scar and healthy tissue are required for different catheters.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 11 May 2023; epub ahead of print</small></div>

<div><h4>Electronic alerts for ambulatory patients with atrial fibrillation not prescribed anticoagulation: A randomized, controlled trial (AF-ALERT2).</h4><i>Piazza G, Hurwitz S, Campia U, Bikdeli B, ... Glezer A, Goldhaber SZ</i><br /><b>Background</b><br />Despite widely available risk stratification tools, safe and effective anticoagulants, and guideline recommendations, anticoagulation for stroke prevention in atrial fibrillation (AF) is under-prescribed in ambulatory patients. To assess the impact of alert-based computerized decision support (CDS) on anticoagulation prescription in ambulatory patients with AF and high-risk for stroke, we conducted this randomized controlled trial.<br /><b>Methods</b><br />Patients with AF and CHA<sub>2</sub>DS<sub>2</sub><sub>-</sub>VASc score ≥ 2 who were not prescribed anticoagulation and had a clinic visit at Brigham and Women\'s Hospital were enrolled. Patients were randomly allocated, according to Attending Physician of record, to intervention (alert-based CDS) versus control (no notification). The primary efficacy outcome was the frequency of anticoagulant prescription.<br /><b>Results</b><br />The CDS tool assigned 395 and 403 patients to the alert and control groups, respectively. Alert patients were more likely to be prescribed anticoagulation within 48 h of the clinic visit (15.4 % vs. 7.7 %, p < 0.001) and at 90 days (17.2 % vs. 9.9 %, p < 0.01). Direct oral anticoagulants were the predominantly prescribed form of anticoagulation. No significant differences were observed in stroke, TIA, or systemic embolic events (0 % vs. 0.8 %, p = 0.09), symptomatic VTE (0.5 % vs. 1 %, p = 0.43), all-cause mortality (2 % vs. 0.7 %, p = 0.12), or major adverse cardiovascular events (2.8 % vs. 2.5 %, p = 0.79) at 90 days.<br /><b>Conclusions</b><br />An alert-based CDS strategy increased a primary efficacy outcome of anticoagulation in clinic patients with AF and high-risk for stroke who were not receiving anticoagulation at the time of the office visit. The study was likely underpowered to assess an impact on clinical outcomes.<br /><b>Trial registration</b><br />ClinicalTrials.gov Identifier- NCT02958943.<br /><br />Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.<br /><br /><small>Thromb Res: 11 May 2023; 227:1-7</small></div>

<div><h4>Predictors for major in-hospital complications after catheter ablation of ventricular arrhythmias: validation and modification of the Risk in Ventricular Ablation (RIVA) Score.</h4><i>Doldi F, Doldi PM, Plagwitz L, Westerwinter M, ... Varghese J, Eckardt L</i><br /><b>Objective and background</b><br />Catheter-based treatment of patients with ventricular arrhythmias (VA) reduces VA and mortality in selected patients. With regard to potential risks of catheter ablation, a benefit-risk assessment should be carried out. This can be performed with risk scores such as the recently published \"Risk in Ventricular Ablation (RIVA) Score\". We sought to validate this score and to test for possible additional predictors in a large database of VT ablations.<br /><b>Methods and results</b><br />We analyzed 1964 catheter ablations for VA in patients with (1069; 54.4%) and without (893, 45.6%) structural heart disease (SHD) and observed an overall major adverse event rate of 4.0% with an in-hospital mortality of 1.3% with significantly less complications occurring in patients without structural heart disease (6.5% vs. 1.1%; p ≤ 0.01). The RIVA Score demonstrated to be a valid predictive tool for major in-hospital complications (OR 1.18; 95% CI 1.12, 1.25; p ≤ 0.001). NYHA Class ≥ III (OR 2.5; 95% CI 1.5, 4.2; p < 0.001) and age (OR 1.04; 95% CI 1.02, 1.07; p ≤ 0.001) proved to be additional predictive parameters. Hence, a modified RIVA Score (mRIVA) model was analyzed with a subset of established predictors (SHD, eGFR, epicardial puncture) as well as new predictive parameters (age, NYHA Class ≥ III), that achieved a higher predictive value for major complications compared with the model based on all RIVA variables.<br /><b>Conclusion</b><br />Adding age and functional heart failure status (NYHA class) as simple clinical parameters to the recently published RIVA Score increases the predictive value for ablation-associated complications in a large VT ablations registry.<br /><br />© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.<br /><br /><small>Clin Res Cardiol: 10 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>Atrial Fibrillation in Adult Congenital Heart Disease and the General Population.</h4><i>Wu MH, Chiu SN, Tseng WC, Lu CW, Kao FY, Huang SK</i><br /><b>Background</b><br />Atrial fibrillation (AF) among adults with congenital heart disease (ACHD) may appear early, depending on individual characteristics.<br /><b>Objective</b><br />To investigate the epidemiological spectrum of AF in the entire ACHD and compare to the general population.<br /><b>Methods</b><br />A retrospective study on nationwide cohort 2000-2014 with AF onset during 2003-2014.<br /><b>Results</b><br />In ACHD cohort, 2,350 patients had AF; incidence increased with age, plateauing around age 70. In patients aged 25-29, 45-49, 65-69, 75-79, and ≥80 years, the annual incidence was 1.3, 7.9, 20.6, 23.7, and 21.4/1,000, respectively. In the non-ACHD general population, 347,979 patients had AF; the annual incidence was <1/1,000 in those aged <55 years but increased steadily with age (3.6, 8.6, and 14.2/1,000 in aged 65-69, 75-79, and ≥80, respectively). Compared to the non-ACHD, the ACHD aged <50 and both those aged 50-54 and 55-59 exhibited a 20-fold and 10-fold higher incidence of AF, respectively. Patients with complex CHD and Ebstein\'s anomaly had the highest risk of AF (cumulative risk >10% by age 50; >20% by age 60), followed by those with tetralogy of Fallot, tricuspid atresia, endocardial cushion defect, and secundum atrial septal defect (cumulative risk >5% by age 50; >10% by age 60).<br /><b>Conclusion</b><br />Compared with non-ACHD cohort, AF in ACHD likely appeared 30 years earlier, with a 10-20-fold higher incidence plateauing around age 70. Yet, incidence in non-ACHD individuals continued to rise. AF burden in ACHD is not expected to expand in a never-ending way.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 09 May 2023; epub ahead of print</small></div>

<div><h4>Mild elevation of extracellular potassium greatly potentiates the effect of sodium channel block to cardiovert atrial fibrillation: The Lankenau approach.</h4><i>Burashnikov A, Antzelevitch C</i><br /><b>Background</b><br />Cardioversion of atrial fibrillation (AF) is a common clinical necessity and there is a need for more effective and safe options for acute cardioversion of AF.<br /><b>Objective</b><br />To test the hypothesis that the efficacy and time course of AF cardioversion by sodium channel current (I<sub>Na</sub>) block can be improved by mild elevation of extracellular potassium ([K<sup>+</sup>]<sub>0</sub>).<br /><b>Methods</b><br />Using a canine acetylcholine (ACh)-mediated AF model (isolated coronary-perfused right atrial preparations with a rim of right ventricle), we evaluated the ability of flecainide to suppress AF in the presence of [K<sup>+</sup>]<sub>0</sub> ranging from 3 to 8 mM.<br /><b>Results</b><br />At [K<sup>+</sup>]<sub>0</sub> of 4 mM (baseline), persistent AF (>1 hour) was induced in 5/5 atria in the presence of 0.5 μM ACh. Flecainide alone (1.5 μM) cardioverted 3/6 atria at 4 mM [K<sup>+</sup>]<sub>0</sub>, 1/6 atria at 3 mM [K<sup>+</sup>]<sub>0</sub>, 5/5 atria at 5 mM and 6 mM [K<sup>+</sup>]<sub>0</sub>, and 4/4 atria at 8 mM [K<sup>+</sup>]<sub>0</sub>. In the absence of flecainide, an increase in [K<sup>+</sup>]<sub>0</sub> from 4 to 5, 6 and 8 mM terminated AF in 0/5, 2/6, and 4/4 atria. The time to conversion was also abbreviated by elevation of [K<sup>+</sup>]<sub>0</sub>. Following AF termination with flecainide plus elevated [K<sup>+</sup>]<sub>0</sub>, AF was either not inducible or brief (< 100 sec). Combined flecainide and elevated [K<sup>+</sup>]<sub>0</sub> (6 mM) caused an atrial preferential depression of excitability.<br /><b>Conclusion</b><br />Our findings suggest that a combination of I<sub>Na</sub> block accompanied by mild elevation of serum potassium may be a novel approach to more effectively, rapidly, and safely cardiovert AF and prevent its recurrence in the short term.<br /><br />Copyright © 2023 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.<br /><br /><small>Heart Rhythm: 09 May 2023; epub ahead of print</small></div>

<div><h4>Prevalence of glucose metabolism disorders and its association with left atrial remodelling before and after catheter ablation in patients with atrial fibrillation.</h4><i>Nakanishi K, Daimon M, Fujiu K, Iwama K, ... Morita H, Komuro I</i><br /><b>Aims</b><br />To investigate the exact prevalence of glucose metabolism disorders, and their impact on left atrial (LA) remodelling and reversibility in patients with atrial fibrillation (AF).<br /><b>Methods and results</b><br />We examined 204 consecutive patients with AF who underwent their first catheter ablation (CA). Oral glucose tolerance test was used to evaluate glucose metabolism disorders in 157 patients without known diabetes mellitus (DM). Echocardiography was performed before and 6 months after CA. Oral glucose tolerance test identified abnormal glucose metabolism in 86 patients [11 with newly diagnosed DM, 74 with impaired glucose tolerance (IGT) and 1 with impaired fasting glucose (IFG)]. Ultimately, 65.2% of patients had abnormal glucose metabolism. Diabetes mellitus group had the worst LA reservoir strain and LA stiffness (both P < 0.05), while there was no significant difference in baseline LA parameters between normal glucose tolerance (NGT) group and IGT/IFG group. The prevalence of LA reverse remodelling (≥15% decrease in the LA volume index at 6 months after CA) was significantly higher in NGT group compared with IGT/IFG and DM group (64.1 vs. 38.6 vs. 41.5%, P = 0.006). Both DM and IFG/IGT carry a significant risk of lack of LA reverse remodelling independent of baseline LA size and AF recurrence.<br /><b>Conclusion</b><br />Approximately 65% of patients with AF who underwent their first CA had abnormal glucose metabolism. Patients with DM had significantly impaired LA function compared with non-DM patients. Impaired glucose tolerance/IFG as well as DM carries significant risk of unfavourable LA reverse remodelling. Our observations may provide valuable information regarding the mechanisms and therapeutic strategies of glucose metabolism-related AF.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 08 May 2023; epub ahead of print</small></div>

<div><h4>Atrial strain and occult atrial fibrillation in cryptogenic stroke patients: a systematic review and meta-analysis.</h4><i>Anagnostopoulos I, Kousta M, Kossyvakis C, Paraskevaidis NT, ... Deftereos S, Giannopoulos G</i><br /><b>Background</b><br />Cryptogenic stroke (CS) remains a significant cause of morbidity. Failure to identify the underlying pathology increases the rate of recurrence. Atrial fibrillation (AF) seems to be responsible for a substantial proportion of CS. Thus, there is an unmet need to identify and properly treat those with silent AF.<br /><b>Purpose</b><br />To investigate the association between left atrial strain and newly diagnosed AF in CS patients.<br /><b>Objectives</b><br />We searched major electronic databases for articles assessing the relationship between either peak left atrial longitudinal (PALS) or peak contractile (PACS) strain-quantified using speckle tracking echocardiography-and the incidence of occult AF during the diagnostic work-up of CS patients.<br /><b>Results</b><br />Eleven studies (two thousand and eighty-one patients) were analyzed. Incidence of occult AF was 19%. Both PALS and PACS were significantly lower in patients with newly diagnosed AF (MD - 8.6%, 95%CI - 10.7 to - 6.4, I<sup>2</sup> 86.4% and MD - 5.5, 95%CI - 6.8 to - 4.2, I<sup>2</sup> 80.8%). According to the diagnostic accuracy meta-analysis, PALS < 20% present 71% (95%CI 47-87%) sensitivity and 71% (95%CI 60-81%) specificity for the diagnosis of occult AF, assuming a prevalence of 20%. The corresponding values for PACS < 11% are 83% (95%CI 57-94%) and 78% (95%CI 56-91%).<br /><b>Conclusion</b><br />Both PALS and PACS are significantly lower in patients with CS and silent AF. It seems that the cut-off values mentioned above could help physicians in identifying patients who may benefit more from prolonged rhythm monitoring. More studies are needed to confirm these findings.<br /><br />© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.<br /><br /><small>Clin Res Cardiol: 08 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>Surgical and transcatheter left atrial appendage closure in patients with atrial fibrillation and hypertrophic cardiomyopathy.</h4><i>Khawaja T, Majmundar M, Zuzek Z, Arora S, ... Mackall JA, Ukaigwe A</i><br /><b>Background</b><br />Patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF) are at increased stroke risk in comparison to those with non-valvular AF not affected by HCM.<br /><b>Objectives</b><br />To investigate the role of left atrial appendage closure (LAAC) in patients with HCM and AF.<br /><b>Methods and results</b><br />We identified patients with HCM and AF using the National Readmission Dataset. Patients were stratified based on LAAC status. The primary efficacy outcome was a composite of ischaemic and haemorrhagic stroke, TIA, and all-cause mortality. The primary safety outcome was a composite of major bleeding and pericardial complications. Patients were matched using inverse probability of treatment weighting. Cox-proportional hazard regression was applied to calculate the hazard ratio (HR) with a 95% confidence interval (CI) on matched cohorts. We identified 71 980 patients with HCM and AF. 1351 (1.9%) patients underwent LAAC. Two hundred and eighty-seven (21.2%) underwent transcatheter LAAC. LAAC was associated with a lower risk of the primary efficacy outcome (2.5% vs. 5.4%, HR: 0.38; 95% CI: 0.17-0.88; P = 0.024), the primary safety outcome (2.9% vs. 6.8%, HR: 0.39; 95% CI: 0.23-0.66, P = 0.001), and reduced major bleeding. The LAAC group trended towards a lower risk of ischaemic stroke and all-cause mortality.<br /><b>Conclusion</b><br />Surgical and transcatheter LAAC was associated with a lower risk of haemorrhagic stroke and major bleeding.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 05 May 2023; epub ahead of print</small></div>

<div><h4>Long-term outcome of thoracoscopic ablation and radiofrequency catheter ablation for persistent atrial fibrillation as a de novo procedure.</h4><i>Kim J, Kim JY, Jeong DS, Chung TW, ... Lee JM, On YK</i><br /><b>Aims</b><br />Limited data are available regarding the efficacy of thoracoscopic ablation as the first procedure for persistent atrial fibrillation (AF). We sought to compare the long-term efficacy of thoracoscopic ablation vs. radiofrequency (RF) catheter ablation as the first procedure for persistent AF.<br /><b>Methods and results</b><br />Between February 2011 and December 2020, 575 patients who underwent ablation for persistent AF were studied. Among them, thoracoscopic ablation was performed in 281 patients, RF catheter ablation in 228, and hybrid ablation in 66. Rhythm, clinical, and safety outcomes during 7-year follow-up were compared. The patients who underwent thoracoscopic ablation were older, had a higher prevalence of stroke, and had a larger left atrial volume than those who underwent RF catheter ablation. In the propensity score-matched population (n = 306), incidences of atrial tachyarrhythmia recurrence were 51.4% in the thoracoscopic ablation group and 62.5% in the RF catheter ablation group [adjusted hazard ratio (HR) 0.869, 95% confidence interval (CI) 0.618-1.223, P = 0.420]. Stroke and total procedural adverse events were not significantly different between thoracoscopic and RF catheter ablation (2.7 vs. 2.5%, P = 0.603, and 7.1 vs. 4.8%, P = 0.374, respectively). The hybrid ablation group showed similar rhythm outcomes compared with both the thoracoscopic and the RF catheter ablation groups. At the redo procedure, pulmonary vein gaps were more frequently observed in the RF catheter ablation group (32.6%) than in the thoracoscopic ablation group (7.9%) and in the hybrid ablation group (8.8%) (P < 0.001).<br /><b>Conclusion</b><br />As a first procedure in persistent AF, thoracoscopic ablation and RF catheter ablation showed comparable efficacy, clinical, and safety outcomes during long-term follow-up.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 05 May 2023; epub ahead of print</small></div>

<div><h4>Clinical Outcomes of Anticoagulated Patients With Atrial Fibrillation After Falls or Head Injury: Insights From RE-LY.</h4><i>Caldeira D, Alves da Silva P, Pinto FJ</i><br /><b>Background</b><br />Falls are always a concern regarding the balance of risk/benefit in patients with atrial fibrillation treated with anticoagulants. In this analysis, we aimed to evaluate the outcomes of patients that had a fall/head injury reported in the RE-LY clinical trial (Randomized Evaluation of Long-Term Anticoagulation Therapy) and to explore the safety of dabigatran (a nonvitamin K antagonist oral anticoagulant).<br /><b>Methods</b><br />We performed a post hoc retrospective analysis of intracranial hemorrhage and major bleeding outcomes in the RE-LY trial with 18 113 individuals with atrial fibrillation, according to the status occurrence of falls (or head injury) reported as adverse events. Multivariate Cox regression models were used to provide adjusted hazard ratio (HR) and 95% CI.<br /><b>Results</b><br />In the study, 974 falls or head injury events were reported among 716 patients (4%). These patients were older and had more frequently comorbidities such as diabetes, previous stroke, or coronary artery disease. Patients with fall had a higher risk of major bleeding (HR, 2.41 [95% CI, 1.90-3.05]), intracranial hemorrhage (HR, 1.69 [95% CI, 1.35-2.13]), and mortality (HR, 3.91 [95% CI, 2.51-6.10]) compared to those who did not have reported falls or head injury. Among patients who had falls, those allocated to dabigatran showed a lower intracranial hemorrhage risk (HR, 0.42 [95% CI, 0.18-0.98]) compared with warfarin.<br /><b>Conclusions</b><br />In this population, the risk of falls is important and confers a worse prognosis, increasing intracranial hemorrhage, and major bleeding. Patients who fell and were under dabigatran was associated with lower intracranial hemorrhage risk than those anticoagulated with warfarin, but the analysis was merely exploratory.<br /><br /><br /><br /><small>Stroke: 05 May 2023; epub ahead of print</small></div>

<div><h4>Non-vitamin K antagonist oral anticoagulants in atrial fibrillation patients without previous oral anticoagulants or stable under warfarin: a nationwide cohort study.</h4><i>Liu SH, Chao TF, Chan YH, Liao JN, ... Lip GYH, Chen SA</i><br /><b>Aims</b><br />Investigations on non-VKA oral anticoagulants (NOACs) for atrial fibrillation (AF) patients without taking any oral anticoagulants (OACs) or staying well on warfarin were limited. We aimed to investigate the associations between stroke prevention strategies and clinical outcomes among AF patients who were previously well without taking any OACs or stayed well on warfarin for years.<br /><b>Methods and results</b><br />The retrospective analysis included a total of 54 803 AF patients who did not experience an ischaemic stroke or intra-cranial haemorrhage (ICH) for years after AF was diagnosed. Among these patients, 32 917 patients who did not receive OACs were defined as the \'original non-OAC cohort\' (group 1), and 8007 patients who continuously received warfarin were defined as the \'original warfarin cohort\' (group 2). In group 1, compared to non-OAC, warfarin showed no significant difference in ischaemic stroke (aHR 0.979, 95%CI 0.863-1.110, P = 0.137) while those initiated NOACs were associated with lower risk (aHR 0.867, 95%CI 0.786-0.956, P = 0.043). When compared to warfarin, the composite of \'ischaemic stroke or ICH\' and \'ischaemic stroke or major bleeding\' was significantly lower in the NOAC initiator with an aHR of 0.927 (95%CI 0.865-0.994; P = 0.042) and 0.912 (95%CI 0.837-0.994; P < 0.001), respectively. In group 2, when compared to warfarin, those shifted to NOACs were associated with a lower risk of ischaemic stroke (aHR 0.886, 95%CI 0.790-0.993, P = 0.002) and major bleeding (aHR 0.849, 95%CI 0.756-0.953, P < 0.001).<br /><b>Conclusions</b><br />The NOACs should be considered for AF patients who were previously well without taking OACs and those who were free of ischaemic stroke and ICH under warfarin for years.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 05 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>High-Burden Premature Atrial Contractions Predict New-Onset Atrial Fibrillation After Surgical Septal Myectomy.</h4><i>Meng Y, Nie C, Zhang Y, Zhu C, ... Wu Z, Wang S</i><br /><AbstractText>Although increased premature atrial contractions (PACs) reportedly predict atrial fibrillation (AF) in both general and specific (e.g., patients with stroke) populations, early postoperative AF (POAF) risk in patients with increased PAC burden who require cardiac surgery remains unclear. We examined the correlation between different preoperative PAC burdens and POAF in patients with obstructive hypertrophic cardiomyopathy (OHCM) who underwent surgical treatment. We analyzed 304 consecutively admitted patients with OHCM without previous AF who underwent isolated septal myectomy between January 2015 and December 2018. All patients underwent preoperative 24-hour Holter electrocardiogram monitoring. PACs were present in 259 patients (85.20%) and absent in 45 patients (14.80%). According to the cut-off PAC number of 100 beats/24 hours, there were 211 patients (69.41%) with low-burden PACs and 48 patients (15.79%) with high-burden PACs. AF after septal myectomy occurred in 73 patients, which consisted of 3/45 in the non-PAC group (6.67%), 47/211 in the low-PAC-burden group (22.27%), and 23/48 in the high PAC burden group (47.92%). POAF incidence was higher in both low- and high-burden patients than in patients without PAC (p <0.01). Multivariate logistic regression analyses demonstrated that high-burden PACs (p = 0.02) and age (p <0.01) but not low-burden PACs (p = 0.22) independently predicted POAF in patients with OHCM. The area under the receiver operating characteristic curve for preoperative PACs was 0.72 (95% confidence interval 0.66 to 0.79, p <0.01, sensitivity: 68.49%, specificity: 69.26%). In conclusion, POAF incidence was significantly higher in patients with preoperative high-burden PACs and can predict POAF in patients with OHCM.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 05 May 2023; 197:46-54</small></div>

<div><h4>Stereotactic arrhythmia radioablation: a novel therapy for cardiac arrhythmia.</h4><i>Wang S, Luo H, Mao T, Xiang C, ... Yu L, Jiang H</i><br /><AbstractText>Cardiac arrhythmia is a global health problem, and catheter ablation has been one of its main treatments for decades. However, catheter ablation is an invasive method that cannot reach the deep myocardium, and it carries a considerable risk of side effects and recurrence. Therefore, it is necessary to explore a novel approach is necessary. Stereotactic body radiotherapy(SBRT), which has been widely used in the field of radiation oncology, has recently expanded in the treatment of cardiac arrhythmia; when used in this context, it is known as stereotactic arrhythmia radioablation(STAR). As a non-invasive, effective and well-tolerated treatment, STAR may be a suitable alternative method for patients with cardiac arrhythmia who are resistant or intolerant to catheter ablation. The main particles used to deliver energy in STAR are photons, protons and carbon ions. Most studies have shown the short-term effectiveness of STAR, but problems such as a high long-term recurrence rate with a cumulative VT-free survival from the published literature of 38.6%, and related complications have also emerged. Therefore, in this article, we review the application of SBRT in cardiac arrhythmia, analyze its potential problems and explore methods for improvement.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 05 May 2023; epub ahead of print</small></div>

<div><h4>Hematopoietic Somatic Mosaicism Is Associated With an Increased Risk of Postoperative Atrial Fibrillation.</h4><i>Ninni S, Dombrowicz D, Kuznetsova T, Vicario R, ... Staels B, Montaigne D</i><br /><b>Background</b><br />On-pump cardiac surgery triggers sterile inflammation and postoperative complications such as postoperative atrial fibrillation (POAF). Hematopoietic somatic mosaicism (HSM) is a recently identified risk factor for cardiovascular diseases and results in a shift toward a chronic proinflammatory monocyte transcriptome and phenotype.<br /><b>Objectives</b><br />The aim of this study was to assess the prevalence, characteristics, and impact of HSM on preoperative blood and myocardial myeloid cells as well as on outcomes after cardiac surgery.<br /><b>Methods</b><br />Blood DNA from 104 patients referred for surgical aortic valve replacement (AVR) was genotyped using the HemePACT panel (576 genes). Four screening methods were applied to assess HSM, and postoperative outcomes were explored. In-depth blood and myocardial leukocyte phenotyping was performed in selected patients using mass cytometry and preoperative and postoperative RNA sequencing analysis of classical monocytes.<br /><b>Results</b><br />The prevalence of HSM in the patient cohort ranged from 29%, when considering the conventional HSM panel (97 genes) with variant allelic frequencies ≥2%, to 60% when considering the full HemePACT panel and variant allelic frequencies ≥1%. Three of 4 explored HSM definitions were significantly associated with higher risk for POAF. On the basis of the most inclusive definition, HSM carriers exhibited a 3.5-fold higher risk for POAF (age-adjusted OR: 3.5; 95% CI: 1.52-8.03; P = 0.003) and an exaggerated inflammatory response following AVR. HSM carriers presented higher levels of activated CD64<sup>+</sup>CD14<sup>+</sup>CD16<sup>-</sup> circulating monocytes and inflammatory monocyte-derived macrophages in presurgery myocardium.<br /><b>Conclusions</b><br />HSM is frequent in candidates for AVR, is associated with an enrichment of proinflammatory cardiac monocyte-derived macrophages, and predisposes to a higher incidence of POAF. HSM assessment may be useful in the personalized management of patients in the perioperative period. (Post-Operative Myocardial Incident & Atrial Fibrillation [POMI-AF]; NCT03376165).<br /><br />Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Am Coll Cardiol: 04 May 2023; 81:1263-1278</small></div>

<div><h4>Regional disparity on patient characteristics and perceptions after implantable cardioverter-defibrillator implantation: results from an EHRA patient survey.</h4><i>Januszkiewicz Ł, Barra S, Providencia R, Chun JKR, ... de Asmundis C, Boveda S</i><br /><b>Aims</b><br />The aim of this study was to identify potential regional disparities in characteristics of implantable cardioverter-defibrillator (ICD) recipients, patient perceptions and perspectives after implantation and level of information provided to patients.<br /><b>Methods and results</b><br />The prospective, multicentre, and multinational European Heart Rhythm Association patient Survey \'Living with an ICD\' included patients already implanted with an ICD (median ICD dwell time - 5 years, interquartile range 2-10). An online questionnaire was filled-in by patients invited from 10 European countries. A total of 1809 patients (the majority in their 40s to 70s, 65.5% men) were enrolled, with 877 (48.5%) from Western Europe (group 1), followed by 563 from Central/Eastern Europe (group 2, 31.1%), and 369 from Southern Europe (group 3, 20.4%). A total of 52.9% of Central/Eastern Europe patients reported increased satisfaction after ICD placement compared with 46.6% from Western and 33.1% from Southern Europe (1 vs. 2 P = 0.047, 1 vs. 3 P < 0.001, 2 vs. 3 P < 0.001). About 79.2% of Central/Eastern and 76.0% of Southern Europe patients felt optimally informed at the time of device implantation compared with just 64.6% from Western Europe (1 vs. 2 P < 0.001, 1 vs. 3 P < 0.001, 2 vs. 3 P = ns).<br /><b>Conclusions</b><br />While physicians in Southern Europe should address the patients\' concerns about the impact of the ICD on quality of life, physicians from Western Europe should focus on improving the quality of information provided to their prospective ICD patients. Novel strategies to address regional differences in patients\' quality of life and provision of information are warranted.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 May 2023; epub ahead of print</small></div>