<div><h4>Longitudinal Changes in Health-Related Quality of Life in Patients With Atrial Fibrillation.</h4><i>Foster-Witassek F, Aebersold H, Aeschbacher S, Ammann P, ... Schwenkglenks M, Swiss‐AF Investigators</i><br /><AbstractText><br /><b>Background:</b><br/>Optimizing health-related quality of life (HRQoL) is an important aim of atrial fibrillation (AF) treatment. Little is known about patients\' long-term HRQoL trajectories and the impact of patient and disease characteristics. The aim of this study was to describe HRQoL trajectories in an observational AF study population and in clusters of patients with similar patient and disease characteristics. Methods and Results We used 5-year follow-up data from the Swiss-Atrial Fibrillation prospective cohort, which enrolled 2415 patients with prevalent AF from 2014 to 2017. HRQoL data, collected yearly, comprised EuroQoL-5 dimension utilities and EuroQoL visual analog scale scores. Patient clusters with similar characteristics at enrollment were identified using hierarchical clustering. HRQoL trajectories were analyzed descriptively and with inverse probability-weighted regressions. Effects of postbaseline clinical events were additionally assessed using time-shifted event variables. Among 2412 (99.9%) patients with available baseline HRQoL, 3 clusters of patients with AF were identified, which we characterized as follows: \"cardiovascular dominated,\" \"isolated symptomatic,\" and \"severely morbid without cardiovascular disease.\" Utilities and EuroQoL visual analog scale scores remained stable over time for the full population and the clusters; isolated symptomatic patients showed higher levels of HRQoL. Utilities were reduced after occurrences of stroke, hospitalization for heart failure, and bleeding, by -0.12 (95% CI, -0.18 to -0.06), -0.10 (95% CI, -0.13 to -0.08), and -0.06 (95% CI, -0.08 to -0.04), respectively, on a 0 to 1 utility scale. Utility of surviving patients returned to preevent levels 4 years after heart failure hospitalization; 3 years after bleeding; and 1 year after stroke. <br /><b>Conclusions:</b><br/>In patients with prevalent AF, HRQoL was stable over time, irrespective of baseline patient characteristics. Clinical events of hospitalization for heart failure, stroke, and bleeding had only a temporary effect on HRQoL.</AbstractText><br /><br /><br /><br /><small>J Am Heart Assoc: 07 Nov 2023; 12:e031872</small></div>

<div><h4>Benefits and Harms of Standard Versus Reduced-Dose Direct Oral Anticoagulant Therapy for Older Adults With Multiple Morbidities and Atrial Fibrillation.</h4><i>Hayes KN, Zhang T, Kim DH, Daiello LA, ... Berry SD, Zullo AR</i><br /><AbstractText><br /><b>Background:</b><br/>Dose reduction of direct oral anticoagulant (DOAC) medications is inconsistently applied to older adults with multiple morbidities, potentially due to perceived harms and unknown benefits of standard dosing. Methods and Results Using 2013 to 2017 US Medicare claims linked to Minimum Data Set records, we conducted a retrospective cohort study. We identified DOAC initiators (apixaban, dabigatran, rivaroxaban) aged ≥65 years with nonvalvular atrial fibrillation residing in a nursing home. We estimated inverse-probability of treatment weights for DOAC dose using propensity scores. We examined safety (hospitalization for major bleeding) and effectiveness outcomes (all-cause mortality, thrombosis [myocardial infarction, stroke, systemic embolism, venous thromboembolism]). We estimated hazard ratios (HRs) and 95% CIs using cause-specific hazard-regression models. Of 21 878 DOAC initiators, 48% received reduced dosing. The mean age of residents was 82.0 years, 66% were female, and 31% had moderate/severe cognitive impairment. After estimating inverse-probability of treatment weights, standard dosing was associated with a higher rate of bleeding (HR, 1.18 [95% CI, 1.03-1.37]; 9.4 versus 8.0 events per 100 person-years). Standard-dose therapy was associated with the highest rates of bleeding among those aged >80 years (9.1 versus 6.7 events per 100 person-years) and with a body mass index <30 kg/m<sup>2</sup> (9.4 versus 7.4 events per 100 person-years). There was no association of dosing with mortality (HR, 0.99 [95% CI, 0.96-1.06]) or thrombotic events (HR, 1.16 [95% CI, 0.96-1.41]). <br /><b>Conclusions:</b><br/>In this nationwide study of nursing home residents with nonvalvular atrial fibrillation, we found a higher rate of bleeding and little difference in effectiveness of standard versus reduced-dose DOAC treatment. Our results support the use of reduced-dose DOACs for many older adults with multiple morbidities.</AbstractText><br /><br /><br /><br /><small>J Am Heart Assoc: 07 Nov 2023; 12:e029865</small></div>

<div><h4>Natriuretic Peptide Receptor B Protects Against Atrial Fibrillation by Controlling Atrial cAMP Via Phosphodiesterase 2.</h4><i>Dorey TW, Liu Y, Jansen HJ, Bohne LJ, ... Fedak PWM, Rose RA</i><br /><b>Background</b><br />β-AR (β-adrenergic receptor) stimulation regulates atrial electrophysiology and Ca<sup>2+</sup> homeostasis via cAMP-dependent mechanisms; however, enhanced β-AR signaling can promote atrial fibrillation (AF). CNP (C-type natriuretic peptide) can also regulate atrial electrophysiology through the activation of NPR-B (natriuretic peptide receptor B) and cGMP-dependent signaling. Nevertheless, the role of NPR-B in regulating atrial electrophysiology, Ca<sup>2+</sup> homeostasis, and atrial arrhythmogenesis is incompletely understood.<br /><b>Methods</b><br />Studies were performed using atrial samples from human patients with AF or sinus rhythm and in wild-type and NPR-B-deficient (NPR-B<sup>+/-</sup>) mice. Studies were conducted in anesthetized mice by intracardiac electrophysiology, in isolated mouse atrial preparations using high-resolution optical mapping, in isolated mouse and human atrial myocytes using patch-clamping and Ca<sup>2+</sup> imaging, and in mouse and human atrial tissues using molecular biology.<br /><b>Results</b><br />Atrial NPR-B protein levels were reduced in patients with AF, and NPR-B<sup>+/-</sup> mice were more susceptible to AF. Atrial cGMP levels and PDE2 (phosphodiesterase 2) activity were reduced in NPR-B<sup>+/-</sup> mice leading to larger increases in atrial cAMP in the presence of the β-AR agonist isoproterenol. NPR-B<sup>+/-</sup> mice displayed larger increases in action potential duration and L-type Ca<sup>2+</sup> current in the presence of isoproterenol. This resulted in the occurrence of spontaneous sarcoplasmic reticulum Ca<sup>2+</sup> release events and delayed afterdepolarizations in NPR-B<sup>+/-</sup> atrial myocytes. Phosphorylation of the RyR2 (ryanodine receptor) and phospholamban was increased in NPR-B<sup>+/-</sup> atria in the presence of isoproterenol compared with the wild type. C-type natriuretic peptide inhibited isoproterenol-stimulated L-type Ca<sup>2+</sup> current through PDE2 in mouse and human atrial myocytes.<br /><b>Conclusions</b><br />NPR-B protects against AF by preventing enhanced atrial responses to β-adrenergic receptor agonists.<br /><br /><br /><br /><small>Circ Arrhythm Electrophysiol: 07 Nov 2023:e012199; epub ahead of print</small></div>

<div><h4>Off-Label Dosing of Direct Oral Anticoagulants Among Inpatients with Atrial Fibrillation in the United States.</h4><i>Sandhu A, Kaltenbach LA, Chiswell K, Shimoga V, ... Varosy PD, Hess PL</i><br /><AbstractText><b>Background:</b> Among patients hospitalized for atrial fibrillation (AF), the frequency of off-label direct oral anticoagulant (DOAC) dosing, associated factors, hospital-level variation, and temporal trends in contemporary practice are unknown. <br /><b>Methods:</b><br/>Using the Get With The Guidelines® Atrial Fibrillation (GWTG-AF) registry, patients admitted from January 1st, 2014 to March 31st, 2020, and discharged on DOAC were stratified according to receipt of under, over, or recommended dosing. Factors associated with off-label dosing (defined as under or overdosing) were identified using logistic regression. Median odds ratio and time-series analyses were used to assess hospital-level variation and temporal trends, respectively. <br /><b>Results:</b><br/>Of 22,470 patients (70.1 +/- 12.1 years, 48.1% female, 82.5% White) prescribed a DOAC at discharge from hospitalization for AF (66% apixaban, 29% rivaroxaban, 5% dabigatran), underdosing occurred among 2006 (8.9%), overdosing among 511 (2.3%), and recommended dosing among 19953 (88.8%). The overall rate of off-label dosing was 11.2%. Patient-related factors associated with off-label dose included age (underdosing: OR 1.06 per 1-year increase [95% CI 1.06-1.07] and overdosing: OR 1.07 per 1-year increase [1.06-1.09]), dialysis dependence (underdosing: OR 5.50 [3.76-8.05] and overdosing: OR 5.47 [2.74-10.88]), female sex (overdosing: OR 0.79 [0.63-0.99]) and weight (overdosing: OR 0.96 per 1-Kg increase [0.95-1.00]). Across hospitals, the adjusted median odds ratio for off-label DOAC dose was 1.45 [95% CI 1.34-1.65] (underdosing: 1.52 [1.39-1.76] and overdosing: 1.32 [1.20-1.84]), indicating significant hospital-level variation. Over the study period, recommended dosing significantly increased over time (81.9% to 90.9%, p<0.0001 for trend) with a corresponding decline in under (14.4% to 6.6%, p<0.0001 for trend) and overdosing (3.8% to 2.5%, p=0.001 for trend). <b>Conclusions:</b> Over 1 in 10 patients hospitalized for AF is discharged on an off-label DOAC dose with significant variation across hospitals. While the proportion of patients receiving recommended dosing has significantly improved over time, opportunities to improve DOAC dosing persist.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 06 Nov 2023; epub ahead of print</small></div>

<div><h4>Use of Atrial Fibrillation Electrograms and T1/T2 Magnetic Resonance Imaging to Define the Progressive Nature of Molecular and Structural Remodeling - A New Paradigm Underlying the Emergence of Persistent Atrial Fibrillation.</h4><i>Rottmann M, Yoo S, Pfenniger A, Mikhailov A, ... Lee DC, Arora R</i><br /><AbstractText><br /><b>Background:</b><br/>The temporal progression states of the molecular and structural substrate in atrial fibrillation (AF) are not well understood. We hypothesized that these can be detected by AF electrograms and magnetic resonance imaging (MRI) parametric mapping. Methods and Results AF was induced in 43 dogs (25-35 kg, ≥1 year) by rapid atrial pacing (RAP) (3-33 weeks, 600 beats/min), and 4 controls were used. We performed high-resolution epicardial mapping (UneMap, 6 atrial regions, both atria, 130 electrodes, distance 2.5mm) and analyzed electrogram cycle length (CL), dominant frequency (DF), organization index (OI) and peak-to-peak bipolar voltage (V<sub>bip</sub>). Implantable telemetry recordings (DSI) were used to quantify parasympathetic nerve activity (PNA) over RAP time. MRI native T1, post-contrast T1, T2 mapping, and extracellular volume fraction (ECV) were assessed (1.5T, Siemens) at baseline and AF. In explanted atrial tissue, DNA oxidative damage (8-OHdG staining) and % fibro-fatty tissue were quantified. CL, OI decreased (R=0.5, P<0.05), (R=0.5, P<0.05) and DF increased (R=0.3, P n.s.) until 80 days of RAP, but not thereafter. In contrast, voltage continued to decrease throughout the duration of RAP (R=0.6, P<0.05). PNA increased post-RAP and plateaued at 80 days. MRI native T1 and T2 times increased with RAP days (R=0.5, P<0.05), (R=0.6, P<0.05) in PLA throughout RAP. Increased RAP days correlated with increasing 8-OHdG levels and with fibrosis % (R=0.5, P<0.05 for both). <br /><b>Conclusions:</b><br/>A combination of AF electrogram characteristics and T1/T2 MRI can detect early-stage AF remodeling (autonomic remodeling, oxidative stress (OS)) and advanced AF remodeling due to OS and fibrosis.</AbstractText><br /><br /><br /><br /><small>J Am Heart Assoc: 06 Nov 2023:e9011; epub ahead of print</small></div>

<div><h4>The impact of early cryoballoon ablation on clinical outcome in patients with atrial fibrillation: From the Korean cryoballoon ablation registry.</h4><i>Kwon CH, Choi JH, Oh IY, Lee SR, ... Cha MJ, Lim HE</i><br /><b>Introduction</b><br />Influence of early atrial fibrillation (AF) ablation, particularly cryoballoon ablation (CBA), on clinical outcome during long-term follow-up has not been clarified. The objective was to determine whether an early CBA (diagnosis-to-ablation of ≤6 months) strategy could affect freedom from AF recurrence after index CBA.<br /><b>Methods</b><br />The study included 2605 patients from Korean CBA registry data with follow-up >12 months after de novo CBA. The primary outcome was recurrence of atrial tachyarrhythmias (ATs) of ≥30-s after a 3-month blanking period.<br /><b>Results</b><br />Compared to patients in early CBA group, patients in late CBA group had higher prevalence of diabetes, congestive heart failure, and chronic kidney disease, and higher mean CHA<sub>2</sub> DS<sub>2</sub> -VAS score. During mean follow-up of >21 months, ATs recurrence was detected in 839 (32.2%) patients. The early CBA group showed a significantly lower 2-year recurrence rate of ATs than the late CBA group (26.1% vs. 31.7%, p = 0.043). In subgroup analysis, the early CBA group showed significantly higher 1-year and 2-year freedom from ATs recurrence than the late CBA group only in paroxysmal atrial fibrillation (PAF) patients in overall and propensity score matched cohorts. Multivariate analysis showed that early CBA was an independent factor for preventing ATs recurrence in PAF (hazard ratio: 0.637; 95% confidence intervals: 0.412-0.984).<br /><b>Conclusion</b><br />Early CBA strategy, resulting in significantly lower ATs recurrence during 2-year follow-up after index CBA, might be considered as an initial rhythm control therapy in patients with paroxysmal AF.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 05 Nov 2023; epub ahead of print</small></div>

<div><h4>Impact of intracardiac echocardiography versus transesophageal echocardiography guidance on left atrial appendage occlusion procedures: A meta-analysis.</h4><i>Diaz JC, Bastidas O, Duque M, Marín JE, ... Sauer WH, Romero JE</i><br /><b>Background</b><br />Intracardiac echocardiography (ICE) is increasingly used during left atrial appendage occlusion (LAAO) as an alternative to transesophageal echocardiography (TEE). The objective of this study is to evaluate the impact of ICE versus TEE guidance during LAAO on procedural characteristics and acute outcomes, as well the presence of peri-device leaks and residual septal defects during follow-up.<br /><b>Methods</b><br />All studies comparing ICE-guided versus TEE-guided LAAO were identified. The primary outcomes were procedural efficacy and occurrence of procedure-related complications. Secondary outcomes included lab efficiency (defined as a reduction in in-room time), procedural time, fluoroscopy time, and presence of peri-device leaks and residual interatrial septal defects (IASD) during follow-up.<br /><b>Results</b><br />Twelve studies (n = 5637) were included. There were no differences in procedural success (98.3% vs. 97.8%; OR 0.73, 95% CI 0.42-1.27, p = .27; I<sup>2</sup>  = 0%) or adverse events (4.5% vs. 4.4%; OR 0.81 95% CI 0.56-1.16, p = .25; I<sup>2</sup>  = 0%) between the ICE-guided and TEE-guided groups. ICE guidance reduced in in-room time (mean-weighted 28.6-min reduction in in-room time) without differences in procedural time or fluoroscopy time. There were no differences in peri-device leak (OR 0.93, 95% CI 0.68-1.27, p = 0.64); however, an increased prevalence of residual IASD was observed with ICE-guided versus TEE-guided LAAO (46.3% vs. 34.2%; OR 2.23, 95% CI 1.05-4.75, p = 0.04).<br /><b>Conclusion</b><br />ICE guidance is associated with similar procedural efficacy and safety, but could result in improved lab efficiency (as established by a significant reduction in in-room time). No differences in the rate of periprocedural leaks were found. A higher prevalence of residual interatrial septal defects was observed with ICE guidance.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 05 Nov 2023; epub ahead of print</small></div>

<div><h4>Comparison of diagnostic accuracy of current left bundle branch block and ventricular pacing ECG criteria for detection of occlusion myocardial infarction.</h4><i>Lindow T, Mokhtari A, Nyström A, Koul S, Smith SW, Ekelund U</i><br /><b>Background</b><br />Electrocardiographic detection of patients with occlusion myocardial infarction (OMI) can be difficult in patients with left bundle branch block (LBBB) or ventricular paced rhythm (VPR) and several ECG criteria for the detection of OMI in LBBB/VPR exist. Most recently, the Barcelona criteria, which includes concordant ST deviation and discordant ST deviation in leads with low R/S amplitudes, showed superior diagnostic accuracy but has not been validated externally. We aimed to describe the diagnostic accuracy of four available ECG criteria for OMI detection in patients with LBBB/VPR at the emergency department.<br /><b>Methods</b><br />The unweighted Sgarbossa criteria, the modified Sgarbossa criteria (MSC), the Barcelona criteria and the Selvester criteria were applied to chest pain patients with LBBB or VPR in a prospectively acquired database from five emergency departments.<br /><b>Results</b><br />In total, 623 patients were included, among which 441 (71%) had LBBB and 182 (29%) had VPR. Among these, 82 (13%) patients were diagnosed with AMI, and an OMI was identified in 15 (2.4%) cases. Sensitivity/specificity of the original unweighted Sgarbossa criteria were 26.7/86.2%, for MSC 60.0/86.0%, for Barcelona criteria 53.3/82.2%, and for Selvester criteria 46.7/88.3%. In this setting with low prevalence of OMI, positive predictive values were low (Sgarbossa: 4.6%; MSC: 9.4%; Barcelona criteria: 6.9%; Selvester criteria: 9.0%) and negative predictive values were high (all >98.0%).<br /><b>Conclusions</b><br />Our results suggests that ECG criteria alone are insufficient in predicting presence of OMI in an ED setting with low prevalence of OMI, and the search for better rapid diagnostic instruments in this setting should continue.<br /><br />Copyright © 2023 The Author. Published by Elsevier B.V. All rights reserved.<br /><br /><small>Int J Cardiol: 04 Nov 2023:131569; epub ahead of print</small></div>

<div><h4>No Effect of Continued Antiarrhythmic Drug Treatment on Top of Optimized Pulmonary Vein Isolation in Patients With Persistent Atrial Fibrillation: Results From the POWDER-AF2 Trial.</h4><i>Demolder A, O\'Neill L, El Haddad M, Scherr D, ... Tavernier R, Duytschaever M</i><br /><b>Background</b><br />In patients with persistent atrial fibrillation (PersAF), catheter ablation aiming for pulmonary vein isolation (PVI) is associated with moderate clinical effectiveness. We investigated the benefit of continuing previously ineffective class 1C or 3 antiarrhythmic drug therapy (ADT) in the setting of a standardized PVI-only ablation strategy.<br /><b>Methods</b><br />In this multicenter, randomized controlled study, patients with PersAF (≥7 days and <12 months) despite ADT were prospectively randomized 1:1 to PVI with ADT continued versus discontinued beyond the blanking period (ADT ON versus ADT OFF). Standardized catheter ablation was performed aiming for durable isolation with stable, contiguous, and optimized radio frequency applications encircling the pulmonary veins (CLOSE protocol). Clinical visits and 1-to-7-day Holter were performed at 3, 6, and 12 months. The primary end point was any documented atrial tachyarrhythmia lasting >30 seconds beyond 3 months. Prospectively defined secondary end points included repeat ablations, unscheduled arrhythmia-related visits, and quality of life among groups.<br /><b>Results</b><br />Of 200 PersAF patients, 98 were assigned to ADT OFF and 102 to ADT ON. The longest atrial fibrillation episode qualifying for PersAF was 28 (10-90) versus 30 (11-90) days. Clinical characteristics and procedural characteristics were similar. Recurrence of atrial tachyarrhythmia was comparable in both groups (20% OFF versus 21.2% ON). No differences were observed in repeat ablations and unscheduled arrhythmia-related visits. Marked improvement in quality of life was observed in both groups.<br /><b>Conclusions</b><br />In patients with PersAF, there is no benefit in continuing previously ineffective ADT beyond the blanking period after catheter ablation. The high success rate of PVI-only might be explained by the high rate of durable isolation after optimized PVI and the early stage of PersAF (POWDER-AF2).<br /><b>Registration</b><br />URL: https://www.<br /><b>Clinicaltrials</b><br />gov; Unique identifier: NCT03437356.<br /><br /><br /><br /><small>Circ Arrhythm Electrophysiol: 03 Nov 2023:e012043; epub ahead of print</small></div>

<div><h4>Mortality trends, disparities, and social vulnerability in cardiac arrest mortality in the young: A cross-sectional analysis.</h4><i>Ibrahim R, Shahid M, Srivathsan K, Sorajja D, Deshmukh A, Lee JZ</i><br /><b>Background</b><br />Cardiac arrest (CA) is a leading cause of death in the United States (US). Social determinants of health may impact CA outcomes. We aimed to assess mortality trends, disparities, and the influence of the social vulnerability index (SVI) on CA outcomes in the young.<br /><b>Methods</b><br />We conducted a cross-sectional analysis of age-adjusted mortality rates (AAMRs) related to CA in the United States from the Years 1999 to 2020 in individuals aged 35 years and younger. Data were obtained from death certificates and analyzed using log-linear regression models. We examined disparities in mortality rates based on demographic variables. We also explored the impact of the SVI on CA mortality.<br /><b>Results</b><br />A total of 4792 CA deaths in the young were identified. Overall AAMR decreased from 0.20 in 1999 to 0.14 in 2020 with an average annual percentage change of -1.3% (p = .001). Black (AAMR: 0.30) and male populations (AAMR: 0.14) had higher AAMR compared with White (AAMR: 0.11) and female (AAMR: 0.11) populations, respectively. Nonmetropolitan (AAMR: 0.29) and Southern (AAMR: 0.26) regions were also impacted by higher AAMR compared with metropolitan (AAMR: 0.11) and other US census regions, respectively. A higher SVI was associated with greater mortality risks related to CA (risk ratio: 1.82 [95% CI, 1.77-1.87]).<br /><b>Conclusions</b><br />Our analysis of CA in the young revealed disparities based on demographics, with a decline in AAMR from 1999 to 2020. There is a correlation between a higher SVI and increased CA mortality risk, highlighting the importance of targeted interventions to address these disparities effectively.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Nov 2023; epub ahead of print</small></div>

<div><h4>Long-term outcomes of patients with ventricular arrhythmias and negative programmed ventricular stimulation followed with implantable loop recorders: Impact of delayed-enhancement cardiac magnetic resonance imaging.</h4><i>Gupte T, Liang JJ, Latchamsetty R, Crawford T, ... Bogun F, Ghannam M</i><br /><b>Background</b><br />Programed ventricular stimulation (PVS) is a risk stratification tool in patients at risk for adverse arrhythmia outcomes. Patients with negative PVS may yet be at risk for adverse arrhythmia-related events, particularly in the presence of symptomatic ventricular arrhythmias (VA).<br /><b>Objective</b><br />To investigate the long-term outcomes of real-world patients with symptomatic VA without indication for device therapy and negative PVS, and to examine the role of cardiac scaring on arrhythmia recurrence.<br /><b>Methods</b><br />Patients with symptomatic VA, and late gadolinium enhancement cardiac magnetic resonance imaging (LGE-CMR), and negative PVS testing were included. All patients underwent placement of implantable cardiac monitors (ICM). Survival analysis was performed to investigate the impact of LGE-CMR findings on survival free from adverse arrhythmic events.<br /><b>Results</b><br />Seventy-eight patients were included (age 60 ± 14 years, women n = 36 (46%), ejection fraction 57 ± 9%, cardiomyopathy n = 26 (33%), mitral valve prolapse [MVP] n = 9 (12%), positive LGE-CMR scar n = 49 (62%), history of syncope n = 23 (29%)) including patients with primarily premature ventricular contractions (n = 21) or nonsustained VA (n = 57). Patients were followed for 1.6 ± 1.5 years during which 14 patients (18%) experienced VA requiring treatment (n = 14) or syncope due to bradycardia (n = 2). Four/9 patients (44%) with MVP experienced VA (n = 3) or syncope (n = 1). Baseline characteristics between those with and without adverse events were similar (p > 0.05); however, the presence of cardiac scar on LGE-CMR was independently associated with an increased risk of adverse events (hazard ratio: 5.6 95% confidence interval: [1.2-27], p = 0.03, log-rank p = 0.03).<br /><b>Conclusions</b><br />In a real-world cohort with long-term follow-up, adverse arrhythmic outcomes occurred in 18% of patients with symptomatic VA despite negative PVS, and this risk was significantly greater in patients with positive DE-CMR scar. Long term-monitoring, including the use of ICM, may be appropriate in these patients.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Nov 2023; epub ahead of print</small></div>

<div><h4>Prevention of cerebral thromboembolism by oral anticoagulation with dabigatran after pulmonary vein isolation for atrial fibrillation: the ODIn-AF trial.</h4><i>Schrickel JW, Beiert T, Linhart M, Luetkens JA, ... Coenen M, Nickenig G</i><br /><b>Background:</b><br/>and objectives</b><br />Long-term oral anticoagulation (OAC) following successful catheter ablation of atrial fibrillation (AF) remains controversial. Prospective data are missing. The ODIn-AF study aimed to evaluate the effect of OAC on the incidence of silent cerebral embolic events and clinically relevant cardioembolic events in patients at intermediate to high risk for embolic events, free from AF after pulmonary vein isolation (PVI).<br /><b>Methods</b><br />This prospective, randomized, multicenter, open-label, blinded endpoint interventional trial enrolled patients who were scheduled for PVI to treat paroxysmal or persistent AF. Six months after PVI, AF-free patients were randomized to receive either continued OAC with dabigatran or no OAC. The primary endpoint was the incidence of new silent micro- and macro-embolic lesions detected on brain MRI at 12 months of follow-up compared to baseline. Safety analysis included bleedings, clinically evident cardioembolic, and serious adverse events (SAE).<br /><b>Results</b><br />Between 2015 and 2021, 200 patients were randomized into 2 study arms (on OAC: n = 99, off OAC: n = 101). There was no significant difference in the occurrence of new cerebral microlesions between the on OAC and off OAC arm [2 (2%) versus 0 (0%); P = 0.1517] after 12 months. MRI showed no new macro-embolic lesion, no clinical apparent strokes were present in both groups. SAE were more frequent in the OAC arm [on OAC n = 34 (31.8%), off OAC n = 18 (19.4%); P = 0.0460]; bleedings did not differ.<br /><b>Conclusion</b><br />Discontinuation of OAC after successful PVI was not found to be associated with an elevated risk of cerebral embolic events compared with continued OAC after a follow-up of 12 months.<br /><br />© 2023. The Author(s).<br /><br /><small>Clin Res Cardiol: 03 Nov 2023; epub ahead of print</small></div>

<div><h4>Temporal Relation Between Myocardial Infarction And New-onset Atrial Fibrillation - Results From a Nationwide Registry Study.</h4><i>Karlsson E, Kiviniemi T, Halminen O, Lehtonen O, ... Lehto M, FinACAF study group</i><br /><AbstractText>Myocardial infarction (MI) and atrial fibrillation (AF) are commonly seen in the same patient. In this study we evaluated the temporal relations and prognosis of MI and AF. This is a sub-study of the nationwide registry-based, Finnish Anticoagulation in Atrial Fibrillation (FinACAF-study), comprising all Finnish patients with new-onset AF during 2010 to 2017. Patients with MI and AF were divided into groups depending on the temporal relation between the disease onsets; (1) MI before AF (MI<AF), (2) MI ± 30 days before or after AF (MI=AF), (3) MI after AF (MI>AF), and (4) no MI. One-year mortality in the groups were studied with Cox proportional hazards model. Of the 153,207 patients with new-onset AF (mean-age 72.7; 50.0% female), 16,265 (10.6%) were diagnosed with MI. Altogether 8,889 (54.7%) of the MI patients where in the MI<AF group, 4,278 (26.3%) were in the MI=AF group; and 3,098 (19.1%) in the MI>AF group. Of all MIs 42.2% were diagnosed within 1 year from new-onset AF. The MI>AF group had the worst survival with an adjusted HR for death of 3.08 (CI 2.89 to 3.27) compared to patients with no MI. For the MI<AF and MI=AF groups the HRs were 1.34 (CI 1.27 to 1.41) and 1.69 (CI 1.59 to 1.81). In conclusion, the diagnoses of MI and AF accumulated close to one another, and the survival of patients with concomitant AF and MI varied, with the worst outcome found in patients with MI diagnosed after the new-onset AF.</AbstractText><br /><br />Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 02 Nov 2023; epub ahead of print</small></div>

<div><h4>Underlying mechanism of atrial fibrillation associated Nppa-I137T mutation and cardiac effect of potential drug therapy.</h4><i>Huang Y, Wang LL, Liu ZB, Chen C, ... Barajas-Martínez H, Hu D</i><br /><b>Background</b><br />Over a hundred genetic loci have been associated with atrial fibrillation (AF). But the exact mechanism remains unclear and the treatment needs to be improved.<br /><b>Objective</b><br />This study aims to investigate the mechanism and potential treatment of NPPA mutation associated AF.<br /><b>Methods</b><br />The Nppa KI (p.I137T) rats were generated and cardiac function was evaluated. Blood pressure was recorded by a tail cuff system. The expression levels were measured by RT-PCR, ELISA or western blot, and RNA sequence analysis. The programmed electrical stimulation, the patch clamp, and multielectrode array were used to record the electrophysical characteristics.<br /><b>Results</b><br />The mutant rats displayed down-regulated expression of ANP, but elevated blood pressure and enlarged left atrial end-diastolic diameter. Further gene topology analysis suggested the majority of differently expressed genes in Nppa KI rats were related to inflammation, electrical remodeling and structural remodeling. The CCL5 and Galetin-3 expressions involved in remodeling were higher, while there were declined levels of Nav1.5, Cav1.2, and Cx40. AF was more easily induced in KI rat. Electrical remodeling included abbreviated action potentials, effective refractory period, increased late sodium current and reduced calcium current, giving rise to conduction abnormalities. These electrophysiological changes could be reversed by the late sodium current blocker, ranolazine, and the Nav1.8 blocker, A-803467.<br /><b>Conclusion</b><br />Our findings suggest that the structural remodeling related to inflammation and fibrosis, and electrical remodeling involved in late sodium current underly the major effects of the Nppa (p.I137T) variant to induce AF, which can be attenuated by I<sub>Na,L</sub> blocker and Nav1.8 blocker.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 02 Nov 2023; epub ahead of print</small></div>

<div><h4>Heterogeneity of outcomes within diabetic patients with atrial fibrillation on edoxaban: a sub-analysis from the ETNA-AF Europe registry.</h4><i>Patti G, Pecen L, Casalnuovo G, Manu MC, Kirchhof P, De Caterina R</i><br /><b>Background</b><br />Recent data have suggested that insulin-requiring diabetes mostly contributes to the overall increase of thromboembolic risk in patients with atrial fibrillation (AF) on warfarin. We evaluated the prognostic role of a different diabetes status on clinical outcome in a large cohort of AF patients treated with edoxaban.<br /><b>Methods</b><br />We accessed individual patients\' data from the prospective, multicenter, ETNA-AF Europe Registry. We compared the rates of ischemic stroke/transient ischemic attack (TIA)/systemic embolism, myocardial infarction (MI), major bleeding and all-cause death at 2 years according to diabetes status.<br /><b>Results</b><br />Out of an overall population of 13,133 patients, 2885 had diabetes (22.0%), 605 of whom (21.0%) were on insulin. The yearly incidence of ischemic stroke/TIA/systemic embolism was 0.86% in patients without diabetes, 0.87% in diabetic patients not receiving insulin (p = 0.92 vs no diabetes) and 1.81% in those on insulin (p = 0.002 vs no diabetes; p = 0.014 vs diabetes not on insulin). The annual rates of MI and major bleeding were 0.40%, 0.43%, 1.04% and 0.90%, 1.10% and 1.71%, respectively. All-cause yearly mortality was 3.36%, 5.02% and 8.91%. At multivariate analysis, diabetes on insulin was associated with a higher rate of ischemic stroke/TIA/systemic embolism [adjusted HR 2.20, 95% CI 1.37-3.54, p = 0.0011 vs no diabetes + diabetes not on insulin] and all-cause death [aHR 2.13 (95% CI 1.68-2.68, p < 0.0001 vs no diabetes]. Diabetic patients not on insulin had a higher mortality [aHR 1.32 (1.11-1.57), p = 0.0015], but similar incidence of stroke/TIA/systemic embolism, MI and major bleeding, vs those without diabetes.<br /><b>Conclusions</b><br />In a real-world cohort of AF patients on edoxaban, diabetes requiring insulin therapy, rather than the presence of diabetes per se, appears to be an independent factor affecting the occurrence of thromboembolic events during follow-up. Regardless of the diabetes type, diabetic patients had a lower survival compared with those without diabetes.<br /><br />© 2022. The Author(s).<br /><br /><small>Clin Res Cardiol: 01 Nov 2023; 112:1517-1528</small></div>

<div><h4>Clinical Outcomes by Sex After Pulsed Field Ablation of Atrial Fibrillation.</h4><i>Turagam MK, Neuzil P, Schmidt B, Reichlin T, ... Kueffer T, Reddy VY</i><br /><b>Importance</b><br />Previous studies evaluating the association of patient sex with clinical outcomes using conventional thermal ablative modalities for atrial fibrillation (AF) such as radiofrequency or cryoablation are controversial due to mixed results. Pulsed field ablation (PFA) is a novel AF ablation energy modality that has demonstrated preferential myocardial tissue ablation with a unique safety profile.<br /><b>Objective</b><br />To compare sex differences in patients undergoing PFA for AF in the Multinational Survey on the Methods, Efficacy, and Safety on the Postapproval Clinical Use of Pulsed Field Ablation (MANIFEST-PF) registry.<br /><b>Design, setting, and participants</b><br />This was a retrospective cohort study of MANIFEST-PF registry data, which included consecutive patients undergoing postregulatory approval treatment with PFA to treat AF between March 2021 and May 2022 with a median follow-up of 1 year. MANIFEST-PF is a multinational, retrospectively analyzed, prospectively enrolled patient-level registry including 24 European centers. The study included all consecutive registry patients (age ≥18 years) who underwent first-ever PFA for paroxysmal or persistent AF.<br /><b>Exposure</b><br />PFA was performed on patients with AF. All patients underwent pulmonary vein isolation and additional ablation, which was performed at the discretion of the operator.<br /><b>Main outcomes and measures</b><br />The primary effectiveness outcome was freedom from clinically documented atrial arrhythmia for 30 seconds or longer after a 3-month blanking period. The primary safety outcome was the composite of acute (<7 days postprocedure) and chronic (>7 days) major adverse events (MAEs).<br /><b>Results</b><br />Of 1568 patients (mean [SD] age, 64.5 [11.5] years; 1015 male [64.7%]) with AF who underwent PFA, female patients, as compared with male patients, were older (mean [SD] age, 68 [10] years vs 62 [12] years; P < .001), had more paroxysmal AF (70.2% [388 of 553] vs 62.4% [633 of 1015]; P = .002) but had fewer comorbidities such as coronary disease (9% [38 of 553] vs 15.9% [129 of 1015]; P < .001), heart failure (10.5% [58 of 553] vs 16.6% [168 of 1015]; P = .001), and sleep apnea (4.7% [18 of 553] vs 11.7% [84 of 1015]; P < .001). Pulmonary vein isolation was performed in 99.8% of female (552 of 553) and 98.9% of male (1004 of 1015; P = .90) patients. Additional ablation was performed in 22.4% of female (124 of 553) and 23.1% of male (235 of 1015; P = .79) patients. The 1-year Kaplan-Meier estimate for freedom from atrial arrhythmia was similar in male and female patients (79.0%; 95% CI, 76.3%-81.5% vs 76.3%; 95% CI, 72.5%-79.8%; P = .28). There was also no significant difference in acute major AEs between groups (male, 1.5% [16 of 1015] vs female, 2.5% [14 of 553]; P = .19).<br /><br /><b>Conclusion:</b><br/>and relevance</b><br />Results of this cohort study suggest that after PFA for AF, there were no significant sex differences in clinical effectiveness or safety events.<br /><br /><br /><br /><small>JAMA Cardiol: 01 Nov 2023; epub ahead of print</small></div>

<div><h4>Risk Scores for Prediction of Postoperative Atrial Fibrillation After Cardiac Surgery: A Systematic Review and Meta-Analysis.</h4><i>Pandey A, Okaj I, Ichhpuniani S, Tao B, ... Belley-Cote EP, McIntyre WF</i><br /><AbstractText>Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and is associated with poor clinical outcomes. The objective of this systematic review and meta-analysis was to assess the performance of risk scores to predict POAF in cardiac surgery patients. We searched MEDLINE, Embase, and Cochrane CENTRAL for studies that developed/evaluated a POAF risk prediction model. Pairs of reviewers independently screened studies and extracted data. We pooled area under the receiver operating curves (AUCs), sensitivity and specificity, and adjusted odds ratios from multivariable regression analyses using the generic inverse variance method and random effects models. Forty-three studies (n = 63,847) were included in the quantitative synthesis. Most scores were originally developed for other purposes but evaluated for predicting POAF. Pooled AUC revealed moderate POAF discrimination for the EuroSCORE II (AUC 0.59, 95% confidence interval [CI] 0.54 to 0.65), Society of Thoracic Surgeons (AUC 0.60, 95% CI 0.56 to 0.63), EuroSCORE (AUC 0.63, 95% CI 0.58 to 0.68), CHADS<sub>2</sub> (AUC 0.66, 95% CI 0.57 to 0.75), POAF Score (AUC 0.66, 95% CI 0.63 to 0.68), HATCH (AUC 0.67, 95% CI 0.57 to 0.75), CHA<sub>2</sub>DS<sub>2</sub>-VASc (AUC 0.68, 95% CI 0.60 to 0.75) and SYNTAX scores (AUC 0.74, 95% CI 0.71 to 0.78). Pooled analyses at specific cutoffs of the CHA<sub>2</sub>DS<sub>2</sub>-VASc, CHADS<sub>2</sub>, HATCH, and POAF scores demonstrated moderate-to-high sensitivity (range 46% to 87%) and low-to-moderate specificity (range 31% to 70%) for POAF prediction. In conclusion, existing clinical risk scores offer at best moderate prediction for POAF after cardiac surgery. Better models are needed to guide POAF risk stratification in cardiac surgery patients.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 01 Nov 2023; 209:232-240</small></div>

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

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

<div><h4>Effects of Body Mass Index and Blood Pressure on Atrioventricular Block: Two-sample Mendelian Randomization.</h4><i>Chi X, Zhang N, Zhang L, Fan F, ... Xu M, Li J</i><br /><b>Background</b><br />Observational studies have suggested associations between some atherogenic risk factors and atrioventricular block (AV-block).<br /><b>Objective</b><br />The study sought to investigate the causal effects of several cardiometabolic exposures on AV-block and evaluate the role of coronary artery disease (CAD) as a mediator on the causal pathway by mendelian randomization (MR) analysis.<br /><b>Methods</b><br />Two-sample bidirectional MR was firstly performed to assess the causal effects of cardiometabolic traits on AV-block and examine causality inversely. The exposures of interest included body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting glucose, fasting insulin, low-density lipoprotein, high-density lipoprotein and triglyceride. Multivariable MR was then conducted to disentangle the effect of each significant exposure. Finally, mediation effect of CAD on the causal pathways were estimated by two-step two-sample MR.<br /><b>Results</b><br />Genetically predicted elevation of BMI (OR: 1.40, 95% CI: 1.10-1.78, P = 0.006), SBP (OR: 1.02, 95% CI: 1.00-1.03, P = 0.015) and DBP (OR: 1.04, 95%CI: 1.01-1.07, P = 0.005) were significantly associated with increased AV-block risk. Effects of the other exposures were insignificant. There were no reverse causal effects. Multivariable MR showed causal effects of increased BMI, SBP and DBP on AV-block after mutual adjustment. CAD mediated 14.20% (8.82%, 16.46%), 26.32% (25.00%, 26.47%) and 12.20% (7.69%, 15.94%) of AV-block risk from BMI, SBP and DBP, respectively.<br /><b>Conclusion</b><br />Elevated BMI, SBP and DBP exhibited causal effects on AV-block. The impacts were partly mediated by CAD.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 31 Oct 2023; epub ahead of print</small></div>

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

<div><h4>Ventricular arrhythmia burden in ICD patients during the second wave of the COVID-19 pandemic.</h4><i>Rath B, Doldi F, Willy K, Ellermann C, ... Frommeyer G, Eckardt L</i><br /><b>Aim</b><br />COVID-19 has been associated with cardiovascular complications including ventricular arrhythmias (VA) and an increased number of out-of-hospital cardiac arrests. Nevertheless, several authors described a decrease of VA burden in patients with an implantable defibrillator (ICD) during the first wave of the COVID-19 pandemic. The objective of this study was to determine if these observations could be transferred to later periods of the pandemic as well.<br /><b>Methods</b><br />We retrospectively analyzed a total of 1674 patients with an ICD presenting in our outpatient clinic during the second wave of the COVID-19 pandemic and during a control period for the occurrence of VA requiring ICD interventions.<br /><b>Results</b><br />Seven hundred ninety-five patients with an ICD had a device interrogation in our ambulatory clinic during the second wave of the COVID-19 pandemic compared to eight hundred seventy-nine patients in the control period. There was significant higher amount of adequate ICD therapies in the course of the COVID-19 period. Thirty-six patients (4.5%) received in total eighty-five appropriate ICD interventions during COVID-19, whereas only sixteen patients (1.8%) had sustained VA in the control period (p = 0.01).<br /><b>Conclusion</b><br />In contrast to the first wave of COVID-19, which was characterized by a decrease or least stable number of ICD therapies in several centers, we found a significant increase of VA in ICD patients during the second wave of COVID-19. Possible explanations for this observation include higher infectious rates, potential cardiac side effects of the vaccination as well as personal behavioral changes, or reduced utilization of medical services.<br /><br />© 2023. The Author(s).<br /><br /><small>Clin Res Cardiol: 30 Oct 2023; epub ahead of print</small></div>

<div><h4>Realtime Diagnosis from Electrocardiogram Artificial Intelligence-Guided Screening for Atrial Fibrillation with Long Follow-Up (REGAL): Rationale and design of a pragmatic, decentralized, randomized controlled trial.</h4><i>Yao X, Attia ZI, Behnken EM, Hart MS, ... Friedman PA, Noseworthy PA</i><br /><b>Background</b><br />Atrial fibrillation (AF) is associated with increased risks of stroke and dementia. Early diagnosis and treatment could reduce the disease burden, but AF is often undiagnosed. An artificial intelligence (AI) algorithm has been shown to identify patients with previously unrecognized AF; however, monitoring these high-risk patients has been challenging. Consumer wearable devices could be an alternative to enable long-term follow-up.<br /><b>Objectives</b><br />To test whether Apple Watch, used as a long-term monitoring device, can enable early diagnosis of AF in patients who were identified as having high risk based on AI-ECG.<br /><b>Design</b><br />The Realtime diagnosis from Electrocardiogram (ECG) Artificial Intelligence (AI)-Guided Screening for Atrial Fibrillation (AF) with Long Follow-up (REGAL) study is a pragmatic trial that will accrue up to 2,000 older adults with a high likelihood of unrecognized AF determined by AI-ECG to reach our target of 1,420 completed participants. Participants will be 1:1 randomized to intervention or control and will be followed up for two years. Patients in the intervention arm will receive or use their existing Apple Watch and iPhone and record a 30-second ECG using the watch routinely or if an abnormal heart rate notification is prompted. The primary outcome is newly diagnosed AF. Secondary outcomes include changes in cognitive function, stroke, major bleeding, and all-cause mortality. The trial will utilize a pragmatic, digitally-enabled, decentralized design to allow patients to consent and receive follow-up remotely without traveling to the study sites.<br /><b>Summary</b><br />The REGAL trial will examine whether a consumer wearable device can serve as a long-term monitoring approach in older adults to detect AF and prevent cognitive function decline. If successful, the approach could have significant implications on how future clinical practice can leverage consumer devices for early diagnosis and disease prevention.<br /><b>Clinicaltrials</b><br />GOV: : NCT05923359.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Am Heart J: 30 Oct 2023; epub ahead of print</small></div>

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

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

<div><h4>Rurality and Atrial Fibrillation: Patient Perceptions of Barriers and Facilitators to Care.</h4><i>Mann HK, Streiff M, Schultz KC, Halpern DV, ... Johnson AE, Magnani JW</i><br /><AbstractText><br /><b>Background:</b><br/>Patients experience atrial fibrillation (AF) as a complex disease given its adversity, chronicity, and necessity for long-term treatments. Few studies have examined the experience of rural individuals with AF. We conducted qualitative assessments of patients with AF residing in rural, western Pennsylvania to identify barriers and facilitators to care. Methods and Results We conducted 8 semistructured virtual focus groups with 42 individuals living in rural western Pennsylvania using contextually tailored questions to assess participant perspectives. We inductively analyzed focus group transcripts using paragraph-by-paragraph and focused coding to identify themes with the qualitative description approach. We used Krippendorff α scoring to determine interreviewer reliability. We harnessed investigator triangulation to augment the reliability of our findings. We reached thematic saturation after coding 8 focus groups. Participants were 52.4% women, with a median age of 70.9 years (range, 54.5-82.0 years), and most were White race (92.9%). Participants identified medication costliness, invisibility of AF to others, and lack of emergent transportation as barriers to care. Participants described interpersonal support and use of technology as important for AF self-care, and expressed ambivalence about how relationships with health care providers affected AF care. <br /><b>Conclusions:</b><br/>Focus group participants described multiple social and structural barriers to care for AF. Our findings highlight the complexity of the experience of individuals with AF residing in rural western Pennsylvania. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04076020.</AbstractText><br /><br /><br /><br /><small>J Am Heart Assoc: 27 Oct 2023:e031152; epub ahead of print</small></div>

<div><h4>Cardiac Resynchronisation using Fusion Pacing during Exercise.</h4><i>Green PG, Monteiro C, Holdsworth DA, Betts TR, Herring N</i><br /><b>Background:</b><br/>and aims</b><br />Fusion pacing requires correct timing of left ventricular pacing to right ventricular activation, although it is unclear whether this is maintained when AV conduction changes during exercise. We used cardiopulmonary exercise testing (CPET) to compare cardiac resynchronization therapy (CRT) using fusion pacing or fixed atrioventricular delays (AVD).<br /><b>Methods</b><br />Patients 6 months post-CRT implant with PR intervals less than 250 ms performed 2 CPET tests, using either the SyncAV™ algorithm or fixed AVD of 120 ms in a double blinded, randomised, crossover study. All other programming was optimised to produce the narrowest QRS duration (QRSd) possible.<br /><b>Results</b><br />Twenty patients (11 male, age 71 [65-77] years) were recruited. Fixed AVD and fusion programming resulted in similar narrowing of QRSd from intrinsic rhythm at rest (p=0.85). Overall, there was no difference in peak oxygen consumption (V̇O<sub>2</sub> <sup>PEAK</sup> , p=0.19), oxygen consumption at anaerobic threshold (VT1, p=0.42), or in the time to reach either V̇O<sub>2</sub> <sup>PEAK</sup> (p=0.81) or VT1 (p=0.39). The BORG rating of perceived exertion was similar between groups. CPET performance was also analysed comparing whichever programming gave the narrowest QRSd at rest (119 [96-136] vs 134 [119-142] ms, p<0.01). QRSd during exercise (p=0.03), peak O<sub>2</sub> pulse (ml/beat, a surrogate of stroke volume, p=0.03) and cardiac efficiency (watts/ml/kg/min, p=0.04) were significantly improved.<br /><b>Conclusion</b><br />Fusion pacing is maintained during exercise without impairing exercise capacity compared to fixed AVD. However, using whichever algorithm gives the narrowest QRSd at rest is associated with a narrower QRSd during exercise, higher peak stroke volume and improved cardiac efficiency. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 27 Oct 2023; epub ahead of print</small></div>

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

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

<div><h4>Combining conventional technique with fluoroscopy integration module in accessory pathway ablation.</h4><i>Ozcan EE, Turan OE, Yilancioğlu RY, Inevi U, Akdemir B</i><br /><b>Introduction</b><br />Accessory pathway (AP) ablation is a straightforward approach with high success rates, but the fluoroscopy time (FT) is significantly longer in conventional technique. Electroanatomical mapping systems (EMS), reduce the FT, but anatomical and activation mapping may prolong the procedure time (PT). The fluoroscopy integration module (FIM) uses prerecorded fluoroscopy images and allows ablation similar to conventional technique without creating an anatomical map. In this study, we investigated the effects of combining the FIM with traditional technique on PT, success, and radiation exposure.<br /><b>Methods</b><br />A total of 131 patients who had undergone AP ablation were included in our study. In 37 patients, right and left anterior oblique (RAO-LAO) images were acquired after catheter placement and integrated with the FIM. The ablation procedure was then similar to the conventional technique, but without the use of fluoroscopy. For the purpose of acceleration, anatomical and activation maps have not been created. Contact-force catheters were not used. 94 patients underwent conventional ablation using fluoroscopy only.<br /><b>Results</b><br />FIM into AP ablation procedures led to a significant reduction in radiation exposure, lowering FT from 7.4 to 2.8 min (p < .001) and dose-area product from 12.47 to 5.8 μGym² (p < .001). While the FIM group experienced a reasonable longer PT (69 vs. 50 min p < .001). FIM reduces FT regardless of operator experience and location of APs <br /><b>Conclusion:</b><br/>Combining FIM integration with conventional AP ablation offers reduced radiation exposure without compromising success rates and complication.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 27 Oct 2023; epub ahead of print</small></div>

<div><h4>Comparison of transseptal puncture using a dedicated RF wire versus a mechanical needle with and without electrification in an animal model.</h4><i>Knight BP, Wasserlauf J, Al-Dujaili S, Al-Ahmad A</i><br /><b>Introduction</b><br />Mechanical force to achieve transseptal puncture (TSP) using a standard needle may lead to overshooting and injury, and can potentially be avoided using a radiofrequency (RF)-powered needle or wire. Applying electrocautery to needles and guidewires as an alternative to purpose-built RF systems has been associated with safety risks, such as tissue coring and thermal damage. The commercially available AcQCross needle-dilator system (Medtronic) features a sharp open-ended needle for mechanical puncture, as well as a built-in connector to enable energy delivery for RF puncture. This investigation compares the safety and efficacy of the AcQCross needle to the dedicated VersaCross RF wire system and generator (Baylis Medical/Boston Scientific).<br /><b>Methods</b><br />In an ex vivo porcine model, VersaCross wire punctures were performed using 1 s, constant mode (approx. 10 W) with maximum two attempts. AcQCross punctures were performed by applying energy for 2 s using a standard electrosurgical generator at 10 W (max. five attempts), 20 W (max. two attempts), and 30 W (max. two attempts). Efficacy was assessed in terms of puncture success and a number of energy applications required for TSP. Safety was assessed quantitatively as force required for TSP, energy required to puncture, and incidence of tissue coring, as well as by qualitative assessment of puncture sites. Additional qualitative observation of tissue cores and debris were obtained from TSP performed in live swine.<br /><b>Results</b><br />RF TSP was 100% successful using the VersaCross wire with 1.0 ± 0.0 attempts. When power was used with the AcQCross needle, it failed to puncture at low (10 and 20 W) power settings; TSP was achieved with 30 W of energy with 91% success using 1.53 ± 0.51 attempts (p < .05 vs. VC) with greater variability (F<sub>1,33</sub>  = 9223.5, p < .0001). Compared to RF puncture using the VersaCross system, mechanical puncture, alone, using the AcQcross needle required six times more force (8 mm additional forward device displacement) to perforate the septum. Qualitative assessment of puncture sites revealed larger defects and more tissue charring with the AcQCross needle at 30 W compared to punctures with VersaCross wire. Tissue coring with the open-ended AcQCross needle was observed in vivo and measured to occur in 57% of punctures using the ex vivo model; no coring was observed with the closed-tip VersaCross wire.<br /><b>Conclusions</b><br />The AcQCross needle frequently required higher energy of 30 W to achieve RF TSP and was associated with tissue coring and charring, which have been, previously, reported when electrifying a standard open-ended mechanical needle or guidewire. These findings may limit safety and effectiveness compared to the VersaCross system.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 27 Oct 2023; epub ahead of print</small></div>

<div><h4>Comparison of the effect of ethanol infusion into the vein of Marshall between with and without collateral veins.</h4><i>Ishimura M, Yamamoto M, Himi T, Kobayashi Y</i><br /><b>Background</b><br />Despite the potential benefits of ethanol infusion into the vein of Marshall (EIVOM) for atrial fibrillation (AF) ablation, concerns about its reversible and unpredictable effects persist.<br /><b>Objective</b><br />To assess the effectiveness of EIVOM in the vein of Marshall (VOM) with collateral veins (CVs) during mitral isthmus and AF ablation.<br /><b>Methods</b><br />We included 142 AF patients. EIVOM was performed before radiofrequency ablation, and low-voltage areas (<0.5 mV) were measured before, immediately after, and 1 h after EIVOM.<br /><b>Results</b><br />Among the 142 patients, 93 (65%) underwent EIVOM, and among these, 35 (37%) were found to have CVs. In the VOM with CVs group, areas with low voltage measured 0 (0-1.85) cm<sup>2</sup> before EIVOM, 6.9 (4.1-11.2) cm<sup>2</sup> immediately after EIVOM, and 5.7 (3.5-10.6) cm<sup>2</sup> 1 h after EIVOM. Conversely, in the group designated as VOM without CVs-from which the nine leakage cases were excluded-the areas measured 0 (0-1.35) cm<sup>2</sup> , 5.5 (2.6-11.8) cm<sup>2</sup> , and 4.7 (1.8-13.5) cm<sup>2</sup> at the respective time points. MI line block was fully achieved in 89% (31/35) of cases in the VOM with CVs group and 88% (44/49) in the VOM without CVs groups (p = .94). There was no significant difference in the outcome of AF ablation between these groups (log-rank p = .73). Additionally, no significant difference was observed between EIVOM (+) and EIVOM (-) groups (log-rank p = .59).<br /><b>Conclusion</b><br />EIVOM effectively creates MI line block, and its beneficial effects are sustained for at least 1 h after the procedure despite the low-voltage areas showing a slight reduction in size.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 27 Oct 2023; epub ahead of print</small></div>

<div><h4>Clinical outcomes and predictors of delayed echocardiographic response to cardiac resynchronization therapy.</h4><i>Tsurumi N, Inden Y, Yanagisawa S, Hiramatsu K, ... Tsuji Y, Murohara T</i><br /><b>Introduction</b><br />The clinical outcomes and mechanisms of delayed responses to cardiac resynchronization therapy (CRT) remain unclear. We aimed to investigate the differences in outcomes and gain insight into the mechanisms of early and delayed responses to CRT.<br /><b>Methods</b><br />This retrospective study included 110 patients who underwent CRT implantation. Positive response to CRT was defined as ≥15% reduction of left ventricular (LV) end-systolic volume on echocardiography at 1 year (early phase) and 3 years (delayed phase) after implantation. The latest mechanical activation site (LMAS) of the LV was identified using two-dimensional speckle-tracking radial strain analysis.<br /><b>Results</b><br />Seventy-eight (71%) patients exhibited an early response 1 year after CRT implantation. Of 32 non-responders in the early phase, 12 (38%) demonstrated a delayed response, and 20 (62%) were classified as non-responders after 3 years. During the follow-up time of 10.3±0.5 years, the delayed and early responders had a similar prognosis of mortality and heart failure (HF) hospitalization. In contrast, non-responders had a worse prognosis. Multivariate analysis revealed that a longer duration (months) between initial HF hospitalization and CRT (odds ratio [OR], 1.126; 95% confidence interval [CI]: 1.036-1.222; p=0.005), non-exact concordance of LV lead location with LMAS (OR, 32.744; 95%CI: 1.101-973.518; p=0.044), and pre-QRS duration (OR, 0.901;95% CI: 0.827-0.981; p=0.016) were independent predictors of delayed response to CRT compared with early response.<br /><b>Conclusion</b><br />The prognoses were similar regardless of the response time after CRT. A longer history of HF, suboptimal LV lead position, and shorter pre-QRS duration were related to delayed response than early response. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 27 Oct 2023; epub ahead of print</small></div>

<div><h4>Reduction of moderate to severe tricuspid regurgitation after catheter ablation for atrial fibrillation.</h4><i>Cha MJ, Lee SA, Cho MS, Nam GB, Choi KJ, Kim J</i><br /><b>Objective</b><br />Tricuspid regurgitation (TR) is a progressive disease with high mortality and limited medical treatment options, and its association with atrial fibrillation (AF) has been documented. This study aimed to investigate whether successful rhythm control through catheter ablation for AF could reduce TR severity.<br /><b>Methods</b><br />A total of 106 patients with drug-refractory AF with moderate to severe secondary TR who underwent AF ablation were screened from a single-centre ablation registry. Echocardiographic parameter changes (pre-procedure vs 1 day/1 year post-procedure) were analysed. Holter monitoring was performed at 3/6/12 months to assess AF recurrence. The primary outcome was at least one grade TR reduction with its main determinants evaluated.<br /><b>Results</b><br />After excluding 36 patients (prior tricuspid valve surgery, intracardiac devices or insufficient data), 70 patients (aged 63.8±9.7 years, 50% female) were analysed. Of these, 17 (24.3%) had severe TR, 55 (78.6%) persistent AF and all restored sinus rhythm with catheter ablation. The primary outcome was achieved in 53 (75.7%) at 1-year assessment (73.6% of moderate and 82.4% of severe TR). There were significant decreases of vena contracta (6.1→3.2 mm) and tricuspid annular diameter (37.3→32.6 mm) at 1 year. Although 25 patients experienced AF recurrence within 1 year, 56 (80%) patients finally maintained sinus rhythm with medical treatment (87% in patients with TR reduction and 59% without). From the multivariate analysis, sinus rhythm maintenance was the most significant determinant of TR reduction (OR 8.3, 95% CI 1.8 to 37.4).<br /><b>Conclusion</b><br />In patients with AF with moderate to severe TR, more than two-thirds of patients experienced reduced TR severity, with notable improvements in echocardiographic parameters. Sinus rhythm maintenance was associated with significant TR reduction.<br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 25 Oct 2023; epub ahead of print</small></div>

<div><h4>Hypertrophic Cardiomyopathy and Ventricular Preexcitation in the Young: Etiology and Accessory Pathway Characteristics.</h4><i>Przybylski R, Saravu Vijayashankar S, O\'Leary E, Hylind RJ, ... Bezzerides VJ, Abrams DJ</i><br /><b>Background</b><br />The etiology of hypertrophic cardiomyopathy (HCM) in the young is highly varied. Ventricular preexcitation (preexcitation) is well recognized, yet little is known about the specificity of any etiology and the characteristics of the responsible accessory pathways (APs).<br /><b>Methods</b><br />Retrospective cohort study of patients <21 years of age with HCM/preexcitation from 2000 to 2022. The etiology of HCM was defined as isolated HCM, storage disorder, metabolic disease, or genetic syndrome. Atrioventricular APs (true APs) were distinguished from fasciculoventricular fibers (FVFs) using standard invasive electrophysiology study criteria. APs were defined as high risk if any of the following were <250 ms: shortest preexcited RR interval in atrial fibrillation, shortest paced preexcited cycle length, or anterograde AP effective refractory period.<br /><b>Results</b><br />We identified 345 patients with HCM and 28 (8%) had preexcitation (isolated HCM, 10/220; storage disorder, 8/17; metabolic disease, 5/19; and genetic syndrome, 5/89). Six (21%) patients had clinical atrial fibrillation (1 with shortest preexcited RR interval <250 ms). Twenty-two patients underwent electrophysiology study that identified 23 true APs and 16 FVFs. Preexcitation was exclusively FVF mediated in 8 (36%) patients. Five (23%) patients had APs with high-risk conduction properties (including ≥1 patient in each etiologic group). Multiple APs were seen in 8 (36%) and AP plus FVF in 10 (45%) patients. Ablation was acutely successful in 13 of 14 patients with recurrence in 3. One procedure was complicated by CHB after ablation of a high-risk midseptal AP. There were significant differences in QRS amplitude and delta wave amplitude between groups. There were no surface ECG features that differentiated APs from FVFs.<br /><b>Conclusions</b><br />Young patients with HCM and preexcitation have a high likelihood of underlying storage disease or metabolic disease. Nonisolated HCM should be suspected in young patients with large QRS and delta wave amplitudes. Surface ECG is not adequate to discriminate preexcitation from a benign FVF from that secondary to potentially life-threatening APs.<br /><br /><br /><br /><small>Circ Arrhythm Electrophysiol: 25 Oct 2023:e012191; epub ahead of print</small></div>

<div><h4>Concomitant Left Atrial Appendage Occlusion and Transcatheter Aortic Valve Replacement Among Patients with Atrial Fibrillation.</h4><i>Kapadia SR, Krishnaswamy A, Whisenant B, Potluri S, ... Wang Q, Leon MB</i><br /><b>Background</b><br />Atrial fibrillation (AF) is common in patients undergoing transcatheter aortic valve replacement (TAVR) and is associated with increased risk of bleeding and stroke. While left atrial appendage occlusion (LAAO) is approved as an alternative to anticoagulants for stroke prevention in patients with AF, placement of these devices neither in patients with severe AS, nor at the same time as TAVR, has been extensively studied.<br /><b>Methods</b><br />WATCH-TAVR was a multicenter, randomized trial evaluating the safety and effectiveness of concomitant TAVR and LAAO with WATCHMAN in AF patients. Patients were randomized 1:1 to TAVR+LAAO or TAVR+medical therapy. WATCHMAN patients received anticoagulation for 45 days followed by dual antiplatelet therapy until 6 months. Anticoagulation was per treating physician preference for patients randomized to TAVR+medical therapy. The primary non-inferiority endpoint was all-cause mortality, stroke, and major bleeding at 2-years between the two strategies.<br /><b>Results</b><br />The study enrolled 349 patients, 177 TAVR+LAAO and 172 TAVR+medical therapy, between December-2017 and November-2020 at 34 US centers. The mean age was 81 years, CHA<sub>2</sub>DS<sub>2</sub>-VASc score was 4.9 and HAS-BLED score was 3.0. At baseline, 85.4% of patients were taking anticoagulation and 71.3% patients were on antiplatelet therapy. The cohorts were well-balanced for baseline characteristics. The incremental LAAO procedure time was 38 minutes; the median contrast volume was 119 mL for combined procedures versus 70 mL with TAVR alone. At 24 months follow-up, 82.5% compared to 50.8% of patients were on any antiplatelet therapy, and 13.9% compared to 66.7% of patients were on any anticoagulation therapy in TAVR+LAAO compared to TAVR+medical therapy group respectively. For the composite primary endpoint, TAVR+.LAAO was non-inferior to TAVR+ medical therapy (22.7 vs 27.3 events/100 patient years for TAVR+LAAO and TAVR+medical therapy respectively; Hazard Ratio 0.86, 95% CI 0.60 -1.22, P<sub>noninferiority</sub><0.001).<br /><b>Conclusions</b><br />Concomitant WATCHMAN LAAO and TAVR is noninferior to TAVR with medical therapy in severe aortic stenosis patients with AF. The increased complexity and risks of the combined procedure should be considered when concomitant LAAO is viewed as an alternative to medical therapy for patients with AF undergoing TAVR.<br /><br /><br /><br /><small>Circulation: 24 Oct 2023; epub ahead of print</small></div>

<div><h4>RETRO-mapping: A novel algorithm automating wavefront categorization using activation mapping during persistent atrial fibrillation demonstrates a reduction in wavefront collisions following pulmonary vein isolation.</h4><i>Coyle C, Kanella I, Mann I, Qureshi N, Linton NWF, Kanagaratnam P</i><br /><AbstractText>RETRO-mapping was developed to automate activation mapping of atrial fibrillation (AF). We used the algorithm to study the effect of pulmonary vein isolation (PVI) on the frequency of focal, planar, and colliding wavefronts in persistent AF. An AFocusII catheter was placed on the left atrial endocardium to record 3 s of AF at six sites pre and post-PVI in patients undergoing wide circumferential PVI for persistent AF. RETRO-mapping analyzed each segment in 2 ms time windows for evidence of focal, planar, and colliding waveforms and the automated categorizations manually validated. Ten patients were recruited. A total of 360 s of data in 120 segments of 3 s from 60 left atrial locations were analyzed. RETRO-map was highly effective at identifying focal waves and collisions during AF. PVI significantly reduced collision frequency but not focal and planar activation frequency. However, there was a significant reduction in the dispersion of activation directions. Larger studies may help determine factors associated with successful clinical outcome.</AbstractText><br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 23 Oct 2023; epub ahead of print</small></div>

<div><h4>Does asymptomatic atrial fibrillation exist?</h4><i>Carneiro HA, Knight B</i><br /><AbstractText>Atrial fibrillation (AF) is currently defined as symptomatic by asking patients if they are aware of when they are in AF and if they feel better in sinus rhythm. However, this approach of defining AF as symptomatic and asymptomatic fails to adequately consider the adverse effects of AF in patients who are unaware of their rhythm including progression from paroxysmal to persistent AF, and the development of dementia, stroke, sinus node dysfunction, valvular regurgitation, ventricular dysfunction, and heart failure. Labeling these patients as asymptomatic falsely suggests that their AF requires less intense therapy and puts into question the notion of truly asymptomatic AF. Because focusing on patient awareness ignores other important consequences of AF, clinical endpoints that are independent of symptoms are being developed. The concept of AF burden has more recently been used as a clinical endpoint in clinical trials as a more clinically relevant endpoint compared to AF-related symptoms or time to first recurrence, but its correlation with symptoms and other clinical outcomes remains unclear. This review will explore the impact of AF on apparently asymptomatic patients, the use of AF burden as an endpoint for AF management, and potential refinements to the AF burden metric. The review is based on a presentation by the senior author during the 2023 16th annual European Cardiac Arrhythmia Society (ECAS) congress in Paris, France.</AbstractText><br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 23 Oct 2023; epub ahead of print</small></div>

<div><h4>Paroxysmal atrial fibrillation ablation with a novel temperature-controlled CF-sensing catheter: Q-FFICIENCY clinical and healthcare utilization benefits.</h4><i>Hussein AA, Delaughter MC, Monir G, Natale A, ... Osorio J, Q-FFICIENCY investigators</i><br /><b>Introduction</b><br />The prospective, nonrandomized, multicenter Q-FFICIENCY study demonstrated the safety and 12-month efficacy of paroxysmal atrial fibrillation (AF) ablation with the novel QDOT MICRO temperature-controlled, contact force-sensing, radiofrequency (RF) catheter. Participants underwent pulmonary vein isolation with very high-power short-duration (vHPSD) mode (90 W, ≤4 s) alone or combined with conventional-power temperature-controlled (CPTC) mode (25-50 W). This study aimed to assess quality-of-life (QOL) and healthcare utilization (HCU) benefits experienced by Q-FFICIENCY study participants.<br /><b>Methods</b><br />Besides evaluating procedural efficiency, QOL and HCU were assessed through 12 months postablation via Atrial Fibrillation Effect on Quality-of-Life Tool (AFEQT) score, antiarrhythmic drug (AAD) use, and incidence of cardioversion and cardiovascular hospitalization.<br /><b>Results</b><br />Of 191 participants enrolled, 166 were ablated with the new catheter. Compared to baseline, statistically significant, clinically meaningful improvements in composite and subcategories of AFEQT scores were observed at 3 months and sustained through 12 months (12-month increase, 29.3-44.2 points). Class I/III AAD use decreased from 97.6% (162/166) at baseline to 19.6% (31/158) during Months 6-12, representing a significant 79.9% reduction. The cardioversion rate significantly declined by 93.9% from 31.3% (12 months preablation) to 1.9% (evaluation period). One-year Kaplan-Meier estimates of freedom from all-cause and cardiovascular hospitalization were 80.9% (95% confidence interval [CI], 74.8%-86.9%) and 88.8% (95% CI, 84.0%-93.7%), respectively.<br /><b>Conclusions</b><br />Paroxysmal AF ablation with the novel temperature-controlled RF catheter in vHPSD mode, alone or with CPTC mode, led to clinically meaningful improvement in QOL and significant reduction in AAD use, cardioversion, and cardiovascular hospitalization.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 23 Oct 2023; epub ahead of print</small></div>

<div><h4>Incidence and Long-Term Follow-up of Cardiac Implantable Electronic Devices Among Orthotopic Heart Transplant Patients.</h4><i>Gowani Z, Tomashitis B, Ospina MK, Waring A, ... Anderson J, Gold MR</i><br /><b>Background</b><br />Cardiac pacemaker implantation after orthotopic heart transplantation declined dramatically after development of the bicaval anastomosis technique. However, much less is known about the rate, indications, and predictors of device implantations with current surgical technique.<br /><b>Objective</b><br />To evaluate the indications, patient characteristics, incidence, and survival related to cardiac implantable electronic device (CIED) implantation after heart transplant.<br /><b>Methods</b><br />This was a single-center study of 399 consecutive adult orthotopic heart transplant patients with bicaval anastomosis from 1991-2017. The primary endpoint was freedom from pacemaker or ICD implantation, and the secondary endpoint was all-cause mortality.<br /><b>Results</b><br />At transplant, mean ages were 50 ± 12 years (recipient) and 31 + 12 years (donor). CIEDs were implanted in 8% (n=31) of recipients: 11 (35%) pacemakers for sinus node dysfunction, 17 (55%) for high-grade heart block, and 3 (10%) ICDs for primary prevention of sudden cardiac death. Early CIED implantation (< 30 days) was rare and absent for sinus node dysfunction. The risks for CIED increased progressively during follow-up (0-30 years, median 11 years), with low, moderate, and high-risk periods between 0-10, 10-20, and 20-30 years, respectively. Recipients receiving CIEDs survived longer after transplant (21 vs 13 years, p <0.01). Recipients receiving pacemakers for heart block were more likely to receive older donor hearts at the time of transplantation.<br /><b>Conclusion</b><br />Risk of pacemaker implantation increases progressively, while ICD implantation is rare. Donor age is the predominant risk factor for subsequent heart block. Early sinus node dysfunction requiring permanent pacing is rare.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 23 Oct 2023; epub ahead of print</small></div>

<div><h4>Machine Learning for Predicting Postoperative Atrial Fibrillation After Cardiac Surgery: A Scoping Review of Current Literature.</h4><i>El-Sherbini AH, Shah A, Cheng R, Elsebaie A, ... Redfearn D, El-Diasty M</i><br /><AbstractText>Postoperative atrial fibrillation (POAF) occurs in up to 20% to 55% of patients who underwent cardiac surgery. Machine learning (ML) has been increasingly employed in monitoring, screening, and identifying different cardiovascular clinical conditions. It was proposed that ML may be a useful tool for predicting POAF after cardiac surgery. An electronic database search was conducted on Medline, EMBASE, Cochrane, Google Scholar, and ClinicalTrials.gov to identify primary studies that investigated the role of ML in predicting POAF after cardiac surgery. A total of 5,955 citations were subjected to title and abstract screening, and ultimately 5 studies were included. The reported incidence of POAF ranged from 21.5% to 37.1%. The studied ML models included: deep learning, decision trees, logistic regression, support vector machines, gradient boosting decision tree, gradient-boosted machine, K-nearest neighbors, neural network, and random forest models. The sensitivity of the reported ML models ranged from 0.22 to 0.91, the specificity from 0.64 to 0.84, and the area under the receiver operating characteristic curve from 0.67 to 0.94. Age, gender, left atrial diameter, glomerular filtration rate, and duration of mechanical ventilation were significant clinical risk factors for POAF. Limited evidence suggest that machine learning models may play a role in predicting atrial fibrillation after cardiac surgery because of their ability to detect different patterns of correlations and the incorporation of several demographic and clinical variables. However, the heterogeneity of the included studies and the lack of external validation are the most important limitations against the routine incorporation of these models in routine practice. Artificial intelligence, cardiac surgery, decision tree, deep learning, gradient-boosted machine, gradient boosting decision tree, k-nearest neighbors, logistic regression, machine learning, neural network, postoperative atrial fibrillation, postoperative complications, random forest, risk scores, scoping review, support vector machine.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 21 Oct 2023; 209:66-75</small></div>

<div><h4>Up Digital and Personal: How Heart Digital Twins Can Transform Heart Patient Care.</h4><i>Trayanova NA, Prakosa A</i><br /><AbstractText>Precision medicine is the vision of healthcare where therapy is tailored to each patient. As part of this vision, digital twinning technology promises to deliver a digital representation of organs or even patients, using tools capable of simulating personal health conditions and predicting patient or disease trajectories based on relationships learned both from data and from biophysics knowledge. Such virtual replicas would update themselves with data from monitoring devices and medical tests and assessments, reflecting dynamically the changes in our health conditions and the responses to treatment. In precision cardiology, the concepts and initial applications of heart digital twins have slowly been gaining popularity and the trust of the clinical community. In this article, we review the advancement in heart digital twinning and its initial translation to the management of heart rhythm disorders.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 21 Oct 2023; epub ahead of print</small></div>

<div><h4>Concomitant ablation of atrial fibrillation: New pacemakers and early rhythm recovery.</h4><i>Churyla A, McCarthy PM, Kruse J, Andrei AC, ... Passman RS, Cox JL</i><br /><b>Objective</b><br />New permanent pacemaker (PPM) implantation after concomitant atrial fibrillation (AF) ablation has been associated with surgical ablation (SA). We sought to determine factors for PPM use, and early rhythm recovery.<br /><b>Methods</b><br />From 2004 through 2019, 6135 patients underwent valve surgery and were grouped by: No AF (n=4584), AF no SA (n=346), and AF with SA (n=1205) to evaluate predischarge PPM and 3-month rhythm recovery (intrinsic heart rate >40bpm).<br /><b>Results</b><br />Overall, 282 (4.6%) patients required a predischarge PPM: atrioventricular node dysfunction (AVND) in 75.3%, sick sinus syndrome (SSS) in 19.1%, both (5%) and indeterminate (0.7%). Patients with AF had more PPMs: AF with SA (7.9%) versus AF no SA (6.9%) versus No AF (3.6%; P<0.001). For AF patients, PPM rates were not significantly higher for ablation patients (7.6% SA vs 6.9% AF no SA; P=0.56). There were differences in PPM by SA lesion set (biatrial 12.8%; left atrial only 6.1%; pulmonary vein isolation 3.0%; P<0.001). Among AF treated patients with 3-month PPM follow-up, rhythm recovery was common 35/62 (56.5%) and did not differ by lesion set. Rhythm recovery was 63/141 (44.7%) in the AVND group versus 24/35 (68.6%) in the SSS group (P=0.011). In propensity score-matched groups, late survival was similar (P=0.63) for new PPM patients.<br /><b>Conclusions</b><br />Avoiding conduction system trauma and delaying implantation reduces the need for postoperative PPM. Rhythm recovery within 3 months is frequent, especially for patients with SSS. A conservative approach to the implantation of a new PPMs is warranted.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 20 Oct 2023; epub ahead of print</small></div>

<div><h4>Successful ablation of a right concealed epicardial accessory pathway using ethanol infusion.</h4><i>Ma S, Zhu Q, Shu L, Lu Y, Liu C, Cai Z</i><br /><b>Introduction</b><br />This study describes a rare case of concealed epicardial accessory pathway (AP) successfully ablated using ethanol infusion (EI) through a variant vessel connecting the right atrium (RA) and the right ventricle (RV) surface.<br /><b>Methods and results</b><br />A 58-year-old male referred to our hospital for prior failed AP ablation. Cardiac-enhanced computerized tomography scan showed there was a variant vessel at the tip of right atrial appendage and a pulmonary artery (PA)-RA fistula at the roof of RA. The earliest activation was present at the site of the PA-RA fistula. A selective angiography showed that a small branch of the variant vessel covered the earliest excitation site of the AP. EI into this branch successfully repressed the AP without any recurrences within a follow-up period of 3 months.<br /><b>Conclusion</b><br />Endocardial ablation is challenging for epicardial APs related to cardiac structural variations. If small vascular branches near the earliest activation site can be found, EI can successfully ablate these types of epicardial APs.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 19 Oct 2023; epub ahead of print</small></div>

<div><h4>Very high-power short-duration catheter ablation for treatment of cardiac arrhythmias: Insights from the FAST and FURIOUS study series.</h4><i>Heeger CH, Kuck KH, Tilz RR</i><br /><AbstractText>The QDOT MICRO™ Catheter is a novel open-irrigated contact force-sensing radiofrequency ablation catheter. It offers very high-power short-duration (vHPSD) ablation with 90 W for 4 s to improve safety and efficacy of catheter ablation procedures. Although the QDOT MICRO™ Catheter was mainly designed for pulmonary vein isolation (PVI) its versatility to treat atrial fibrillation (AF) and other types of arrhythmias was recently evaluated by the FAST and FURIOUS study series and other studies and will be presented in this article. Available study and registry data as well as case reports concerning utilization of the QDOT MICRO™ Catheter for the treatment of cardiac arrhythmias including AF, focal and macroreentry atrial tachycardia, typical atrial flutter by cavotricuspid isthmus block, premature ventricular contractions, and accessory pathways were reviewed and summarized. In summary, the QDOT MICRO™ Catheter showed safety and efficacy for PVI and is able to treat also other types of arrhythmias as is was recently evaluated by case reports and the FAST and FURIOUS studies.</AbstractText><br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 19 Oct 2023; epub ahead of print</small></div>

<div><h4>Effectiveness and Safety of Nonvitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation at Low Risk of Stroke in Japan: A Retrospective Cohort Study.</h4><i>Uchida M, Jo T, Okada A, Matsui H, Yasunaga H</i><br /><b>Aims</b><br />Contemporary guidelines differ in their recommendations regarding initiating nonvitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) at low risk of stroke. This study aimed to examine the effectiveness and safety of NOACs for low-risk AF in a Japanese cohort.<br /><b>Methods and results</b><br />In this retrospective cohort study based on the JMDC Claims Database extracted between April 2011 and November 2022, we identified 13291 patients with AF at low risk of stroke. We performed inverse probability of treatment weighting Cox regression analyses to compare the embolization and bleeding risks between the nontreatment and NOAC groups. Net clinical benefit was defined as the annual incidence of ischemic stroke events prevented by NOACs after subtracting intracranial hemorrhage (ICH) events attributable to NOACs, multiplied by a weighting factor. The incidences of stroke and ICH in the nontreatment group were 0.47 and 0.15 per 100 person-years, respectively. The NOAC group had higher incidences of ICH (hazard ratio [HR]: 1.73, 95% confidence interval [CI]: 0.75-4.00) and stroke (HR: 1.41, 95% CI: 0.84-2.36). The net clinical benefit of NOAC treatment was -0.35% per year (95% CI: -0.99-0.29%).<br /><b>Conclusion</b><br />NOAC treatment may be associated with a slightlyhigh risk of ICH, and it yielded a neutral clinical benefit in the present Japanese population, which provides reassurance concerning the role of ethnicity in NOAC treatment for patients with AF and suggests a need to assess comprehensive weighting of the respective risk factors.<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: 19 Oct 2023; epub ahead of print</small></div>

<div><h4>Deep Learning of Electrocardiograms in Sinus Rhythm From US Veterans to Predict Atrial Fibrillation.</h4><i>Yuan N, Duffy G, Dhruva SS, Oesterle A, ... Keyhani S, Ouyang D</i><br /><b>Importance</b><br />Early detection of atrial fibrillation (AF) may help prevent adverse cardiovascular events such as stroke. Deep learning applied to electrocardiograms (ECGs) has been successfully used for early identification of several cardiovascular diseases.<br /><b>Objective</b><br />To determine whether deep learning models applied to outpatient ECGs in sinus rhythm can predict AF in a large and diverse patient population.<br /><b>Design, setting, and participants</b><br />This prognostic study was performed on ECGs acquired from January 1, 1987, to December 31, 2022, at 6 US Veterans Affairs (VA) hospital networks and 1 large non-VA academic medical center. Participants included all outpatients with 12-lead ECGs in sinus rhythm.<br /><b>Main outcomes and measures</b><br />A convolutional neural network using 12-lead ECGs from 2 US VA hospital networks was trained to predict the presence of AF within 31 days of sinus rhythm ECGs. The model was tested on ECGs held out from training at the 2 VA networks as well as 4 additional VA networks and 1 large non-VA academic medical center.<br /><b>Results</b><br />A total of 907 858 ECGs from patients across 6 VA sites were included in the analysis. These patients had a mean (SD) age of 62.4 (13.5) years, 6.4% were female, and 93.6% were male, with a mean (SD) CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age, sex category) score of 1.9 (1.6). A total of 0.2% were American Indian or Alaska Native, 2.7% were Asian, 10.7% were Black, 4.6% were Latinx, 0.7% were Native Hawaiian or Other Pacific Islander, 62.4% were White, 0.4% were of other race or ethnicity (which is not broken down into subcategories in the VA data set), and 18.4% were of unknown race or ethnicity. At the non-VA academic medical center (72 483 ECGs), the mean (SD) age was 59.5 (15.4) years and 52.5% were female, with a mean (SD) CHA2DS2-VASc score of 1.6 (1.4). A total of 0.1% were American Indian or Alaska Native, 7.9% were Asian, 9.4% were Black, 2.9% were Latinx, 0.03% were Native Hawaiian or Other Pacific Islander, 74.8% were White, 0.1% were of other race or ethnicity, and 4.7% were of unknown race or ethnicity. A deep learning model predicted the presence of AF within 31 days of a sinus rhythm ECG on held-out test ECGs at VA sites with an area under the receiver operating characteristic curve (AUROC) of 0.86 (95% CI, 0.85-0.86), accuracy of 0.78 (95% CI, 0.77-0.78), and F1 score of 0.30 (95% CI, 0.30-0.31). At the non-VA site, AUROC was 0.93 (95% CI, 0.93-0.94); accuracy, 0.87 (95% CI, 0.86-0.88); and F1 score, 0.46 (95% CI, 0.44-0.48). The model was well calibrated, with a Brier score of 0.02 across all sites. Among individuals deemed high risk by deep learning, the number needed to screen to detect a positive case of AF was 2.47 individuals for a testing sensitivity of 25% and 11.48 for 75%. Model performance was similar in patients who were Black, female, or younger than 65 years or who had CHA2DS2-VASc scores of 2 or greater.<br /><br /><b>Conclusions:</b><br/>and relevance</b><br />Deep learning of outpatient sinus rhythm ECGs predicted AF within 31 days in populations with diverse demographics and comorbidities. Similar models could be used in future AF screening efforts to reduce adverse complications associated with this disease.<br /><br /><br /><br /><small>JAMA Cardiol: 18 Oct 2023; epub ahead of print</small></div>

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

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

<div><h4>Spontaneous Sinus Rhythm Restoration in Patients With Refractory, Permanent Atrial Fibrillation Who Underwent Conduction System Pacing and Atrioventricular Junction Ablation.</h4><i>Palmisano P, Parlavecchio A, Vetta G, Crea P, ... Accogli M, Coluccia G</i><br /><AbstractText>Ablate and pace (A&P) with conduction system pacing (CSP) improves outcomes in patients with symptomatic permanent atrial fibrillation (AF). Data on spontaneous sinus rhythm restoration (SSRR) in this setting are lacking. This study aimed to assess the incidence and the predictors of SSRR in a population of patients with permanent AF who underwent A&P with CSP. Prospective, observational study, enrolling consecutive patients with symptomatic permanent AF (of documented duration >6 months) and uncontrolled, drug-refractory high ventricular rate, who underwent A&P with CSP. The incidence and predictors of SSRR were prospectively assessed. A total of 107 patients (79.0 ± 9.1 years, 33.6% male, 74.8% with New York Heart Association class ≥III, 56.1% with ejection fraction <40%) were enrolled: 40 received His\' bundle pacing, 67 left bundle branch area pacing. During a median follow-up of 12 months SSRR was observed in 14 patients (13.1%), occurring a median of 3 months after A&P (interquartile range 1 to 6; range 0 to 17). Multivariable analysis identified a duration of permanent AF <12 months (hazard ratio 7.7, p = 0.040) and a left atrial volume index <49 ml/m<sup>2</sup> (hazard ratio 14.8, p = 0.008) as independent predictors of SSRR. In patients with coexistence of both predictors the incidence of SSRR was of 41.4%. In a population of patients with symptomatic, permanent AF, treated with A&P with CSP, SSRR was observed in 13% of patients during follow-up. A duration of permanent AF <12 months and a left atrial volume index <49 ml/m<sup>2</sup> were independent predictors of this phenomenon.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 18 Oct 2023; epub ahead of print</small></div>