Topic: Electrophysiology

Abstract

A review of global health technology assessments of non-VKA oral anticoagulants in non-valvular atrial fibrillation.

Lopes RD, Berger SE, Di Fusco M, Kang A, ... Deshpande S, Mantovani LG
Background
This review assessed global health technology assessment (HTA) reports and recommendations of non-vitamin K oral anticoagulants (NOACs) in non-valvular atrial fibrillation (NVAF).
Methods
NHTA agency websites were searched for HTA reports evaluating NOACs versus NOACs or vitamin K antagonists. HTA methods and information on patient involvement/access were collected and empirically analyzed.
Results
The review identified 38 unique HTA reports published between 2012 and 2017 in 16 countries including 11 in Europe. NOACs that were cost-effective per local willingness-to-pay (WTP) thresholds were positively recommended for the treatment of NVAF. WTP thresholds ranged from €20,000 to 69,000. Apixaban was recommended in 10/12 (83%) countries, dabigatran in 9/13 (69%) countries, and rivaroxaban in 10/13 (76%) over warfarin. Edoxaban was recommended in 5/7 (71%) countries. Economic evaluations and recommendations comparing NOACs were sparse (two or three countries per NOAC) and generally favored apixaban and edoxaban, followed by dabigatran. Eleven HTA reports from four countries considered the patient voice (Canada [n = 3], Scotland [n = 3], England [n = 4], Brazil [n = 1]); however, only 2/11 (18%) developed recommendations based on this. Among the reports with a positive recommendation, 26/30 (87%) featured a decision that aligned with the approved regulatory label.
Conclusions
Most agencies recommended NOACs over warfarin for patients with NVAF. Few countries made statements recommending one NOAC over another. Given different WTP thresholds, a drug that is cost-effective in one market may not be in another. Therefore, the various NOAC recommendations from HTA agencies cannot be generalized across different countries.

Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Nov 2020; 319:85-93
Lopes RD, Berger SE, Di Fusco M, Kang A, ... Deshpande S, Mantovani LG
Int J Cardiol: 14 Nov 2020; 319:85-93 | PMID: 32634487
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Abstract

Impact of the CHADS-VASc score on late clinical outcomes in patients undergoing left atrial appendage occlusion.

Agudelo V, Millán X, Li CH, Asmarats L, ... Serra A, Arzamendi D
Background
Left atrial appendage occlusion (LAAO) is an accepted strategy for cardioembolic events prevention in patients with non-valvular atrial fibrillation (AF) unsuitable for anticoagulation. However, uncertainties persist regarding the benefit of LAAO in highly-comorbid patients. The aim of this study was to assess the impact of the CHADS-VASc score beyond thromboembolic risk in predicting clinical outcomes in patients undergoing LAAO.
Methods
160 patients who underwent LAAO were included and categorized into two groups according to their stroke risk (89 with CHADS-VASc >4 vs. 71 with lower risk). The coprimary endpoints were death and stroke at follow-up. Thromboembolic and bleeding events were compared to those predicted from CHADS-VASc and HAS-BLED scores.
Results
Over a median follow-up of 679 days, CHADS-VASc >4 was associated with increased all-cause mortality compared with patients with lower thromboembolic risk (HR: 3.23; 95% CI: 1.28-8.19; p < 0.001). However, the rates of stroke after LAAO were not significantly different between risk groups. The observed annual rates of stroke and major bleeding were lower than predicted.
Conclusions
Despite increased long-term mortality in patients with CHADS-VASc >4, LAAO remains beneficial in reducing stroke and bleeding events in high-risk AF patients unsuitable for anticoagulation.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Nov 2020; 319:78-84
Agudelo V, Millán X, Li CH, Asmarats L, ... Serra A, Arzamendi D
Int J Cardiol: 14 Nov 2020; 319:78-84 | PMID: 32634500
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Abstract

Accuracy of contrast-enhanced computed tomography for thrombus detection prior to atrial fibrillation ablation and role of novel Left Atrial Appendage Enhancement Index in appendage flow assessment.

Guha A, Dunleavy MP, Hayes S, Afzal MR, ... Raman SV, Harfi TT
Aims
To evaluate diagnostic accuracy of different protocols of contrast enhanced computed tomography venogram (CTV) for LAA thrombus detection in patients undergoing AF ablation and study the correlation of the novel LAA enhancement index (LAA-EI) to LAA flow velocity obtained using transesophageal echocardiography (TEE).
Methods
Study comprised of patients undergoing CTV and TEE on the same day from October 2016 to December 2017. Three CTV scanning protocols (described in results), were evaluated wherein ECG gating was used only for those with sinus rhythm on day of CTV. LAA-EI was calculated as Hounsfield Unit (HU) in the LAA divided by the HU unit in the center of the LA. The diagnostic accuracy for CTV was calculated in comparison to TEE. The LAA-EI was compared to LAA emptying velocities as obtained from TEE.
Results
590 patients with 45.6% non-ECG-gated without delayed imaging, 26.9% non-ECG-gated with delayed imaging and 27.5% ECG-gated with delayed imaging, were included in the study. All three protocols had 100% negative predictive value with improvement in specificity from 61.8% to 98.1% upon adding delayed imaging. The LAA-EI correlated significantly with reduced LAA flow velocities (r = 0.45, p < .0001). The mean LAA emptying velocity in patients with LAA-EI of ≤ 0.6 was significantly lower than in those with LAA-EI of >0.6 (36.2 cm/s [95% CI: 32.6-39.7] vs, (58 cm/s [95% CI 55.3-60.8]), respectively (p < .0001).
Conclusion
CTV with delayed imaging (with or without ECG gating) is highly specific in ruling out LAA thrombus. The novel LAA-EI can detect low LAA flow velocities.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 31 Oct 2020; 318:147-152
Guha A, Dunleavy MP, Hayes S, Afzal MR, ... Raman SV, Harfi TT
Int J Cardiol: 31 Oct 2020; 318:147-152 | PMID: 32629004
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Abstract

Intra-day change in occurrence of out-of-hospital ventricular fibrillation in Japan: The JCS-ReSS study.

Otsuki S, Aiba T, Tahara Y, Nakajima K, ... Kusano K,
Background
Real-world evidence of out-of-hospital ventricular fibrillation (VF), especially regarding intra-day change, remains unclear. We aimed to investigate that age- and gender-dependent difference of intra-day change of VF occurrence.
Method
We enrolled 71,692 patients (males: 56,419 [78.7%], females: 15,273 [21.3%]) in whom cardiac VF had been documented from the 2005-2015 All-Japan Utstein Registry data. Subjects were divided into four groups: group-I (<18 years old), group-II (18-39), group-III (40-69), and group-IV (≥70). Among four groups in each of male and female, we compared the intra-day change of VF occurrence, and evaluated the risk factors of the unfavorable neurologic outcomes at 1 month after VF.
Results
Regardless of age, the incidence of VF was significantly greater in male than in female subjects. In male subjects, VF in group-I, III and IV occurred higher at daytime, however, group-II had no intra-day difference because group-II had a higher VF events at midnight~ early morning compared with other aged groups (Poisson regression analysis, p = .03). While in female, each group showed similar intra-day pattern of VF occurrence. Logistic regression analysis revealed that some of the clinical parameters such as time periods from call receipt to first shock and the presence of bystander cardiopulmonary resuscitation were important for risk of 30-day neurologically unfavorable outcomes.
Conclusions
The intra-day change of VF occurrence was age-dependently different in males but not in females, suggesting age- and gender-dependent differences in underlying cardiac diseases. These might affect the significant difference in unfavorable neurologic outcome.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 31 Oct 2020; 318:54-60
Otsuki S, Aiba T, Tahara Y, Nakajima K, ... Kusano K,
Int J Cardiol: 31 Oct 2020; 318:54-60 | PMID: 32569698
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Abstract

Cardiovascular Events and Mortality in Patients With Atrial Fibrillation and Anemia (from the Fushimi AF Registry).

An Y, Ogawa H, Esato M, Ishii M, ... Akao M,

Data regarding the associations of anemia (hemoglobin level <13.0 g/dl in men and <12.0 g/dl in women) with clinical outcomes in patients with atrial fibrillation (AF) remains scarce. This study sought to investigate the associations of anemia with the incidences of stroke or systemic embolism, major bleeding, heart failure (HF) hospitalization, and all-cause mortality including its causes, using the data from a Japanese community-based survey, the Fushimi AF Registry. A total of 4,169 AF patients were divided into the 3 groups, based on the baseline hemoglobin level: no (n = 2,622), mild (11.0 to <13.0 g/dl for men and <12.0 g/dl for women; n = 880), and moderate/severe anemia (<11.0 g/dl; n = 667). During a median follow-up of 1,464 days, the incidences of major bleeding, HF hospitalization, and mortality increased with higher rates of cardiac death, in accordance with anemic severity. On multivariate analyses, the higher risk of moderate/severe anemia, relative to no anemia, for major bleeding remained statistically significant (hazard ratio [HR]: 2.00, 95% confidential interval [CI]: 1.48 to 2.72). The risks of those with anemia, relative to no anemia, for HF hospitalization (mild; HR: 1.87, 95% CI: 1.51 to 2.31, and moderate/severe; HR: 2.02, 95% CI: 1.59 to 2.57) as well as for mortality (mild; HR: 1.80, 95% CI: 1.50 to 2.16, and moderate/severe; HR: 2.95, 95% CI: 2.45 to 3.55) were also higher, but not for stroke/systemic embolism. These relations were consistent, regardless of the use of oral anticoagulants. In conclusion, anemia was associated with higher risks of HF hospitalization, mortality, and major bleeding in AF patients.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2020; 134:74-82
An Y, Ogawa H, Esato M, Ishii M, ... Akao M,
Am J Cardiol: 31 Oct 2020; 134:74-82 | PMID: 32900468
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Abstract

Thromboembolic and bleeding risk in obese patients with atrial fibrillation according to different anticoagulation strategies.

Patti G, Pecen L, Manu MC, Huber K, ... Kirchhof P, Caterina R
Background
Data on the relationship between body mass index (BMI), thromboembolic events (TEE) and bleeding in patients with atrial fibrillation (AF) are controversial, and further evidence on the risk of such events in obese patients with AF receiving different anticoagulant therapies (OAC) is needed.
Methods and results
We divided a total of 9330 participants from the prospective PREFER in AF and PREFER in AF PROLONGATION registries into BMI quartiles at baseline. Outcome measures were TEE and major bleeding complications at the 1-year follow-up. Without OAC, there was a ≥6-fold increase of TEE in the 4th vs other BMI quartiles (P = .019). OAC equalized the rates of TEE across different BMI strata. The occurrence of major bleeding was highest in patients with BMI in the 1st as well as in the 4th BMI quartile [OR 1.69, 95% CI 1.03-2.78, P = .039 and OR 1.86, 95% CI 1.13-3.04, P = .014 vs those in the 3rd quartile, respectively]. At propensity score-adjusted analysis, the incidence of TEE and major bleeding in obese patients receiving non-vitamin K antagonist oral anticoagulants (NOACs) or vitamin K-antagonist anticoagulants (VKAs) was similar (P ≥ .34).
Conclusions
Our real-world data suggest no obesity paradox for TEE in patients with AF. Obese patients are at higher risk of TEE, and here OAC dramatically reduces the risk of events. We here found a comparable clinical outcome with NOACs and VKAs in obese patients. Low body weight and obesity were also associated with bleeding, and therefore OAC with the best safety profile should be considered in this setting.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 31 Oct 2020; 318:67-73
Patti G, Pecen L, Manu MC, Huber K, ... Kirchhof P, Caterina R
Int J Cardiol: 31 Oct 2020; 318:67-73 | PMID: 32574823
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Abstract

Association of household income and adverse outcomes in patients with atrial fibrillation.

LaRosa AR, Claxton J, O\'Neal WT, Lutsey PL, ... Alonso A, Magnani JW
Background
Social determinants of health are relevant to cardiovascular outcomes but have had limited examination in atrial fibrillation (AF).
Objectives
The purpose of this study was to examine the association of annual household income and cardiovascular outcomes in individuals with AF.
Methods
We analysed administrative claims for individuals with AF from 2009 to 2015 captured by a health claims database. We categorised estimates of annual household income as <$40 000; $40-$59 999; $60-$74 999; $75-$99 999; and ≥$100 000. Covariates included demographics, education, cardiovascular disease risk factors, comorbid conditions and anticoagulation. We examined event rates by income category and in multivariable-adjusted models in reference to the highest income category (≥$100 000).
Results
Our analysis included 336 736 individuals (age 72.7±11.9 years; 44.5% women; 82.6% white, 8.4% black, 7.0% Hispanic and 2.1% Asian) with AF followed for median (25th and 75th percentile) of 1.5 (95% CI 0.6 to 3.0) years. We observed an inverse association between income and heart failure and myocardial infarction (MI) with evidence of progressive risk across decreased income categories. Individuals with household income <$40 000 had the greatest risk for heart failure (HR 1.17; 95% CI 1.05 to 1.30) and MI (HR 1.18; 95% CI 0.98 to 1.41) compared with those with income ≥$100 000.
Conclusions
We identified an association between lower household income and adverse outcomes in a large cohort of individuals with AF. Our findings support consideration of income in the evaluation of cardiovascular risk in individuals with AF.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 30 Oct 2020; 106:1679-1685
LaRosa AR, Claxton J, O'Neal WT, Lutsey PL, ... Alonso A, Magnani JW
Heart: 30 Oct 2020; 106:1679-1685 | PMID: 32144188
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Abstract

Population Trends in All-Cause Mortality and Cause Specific-Death With Incident Atrial Fibrillation.

Singh SM, Abdel-Qadir H, Pang A, Fang J, ... Wijeysundera HC, Ko DT

Background Limited studies have evaluated population-level temporal trends in mortality and cause of death in patients with contemporary managed atrial fibrillation. This study reports the temporal trends in 1-year overall and cause-specific mortality in patients with incident atrial fibrillation. Methods and results Patients with incident atrial fibrillation presenting to an emergency department or hospitalized in Ontario, Canada, were identified in population-level linked administrative databases that included data on vital statistics and cause of death. Temporal trends in 1-year all-cause and cause-specific mortality was determined for individuals identified between April 1, 2007 (fiscal year [FY] 2007) and March 31, 2016 (FY 2015). The study cohort consisted of 110 302 individuals, 69±15 years of age with a median congestive heart failure, hypertension, age (≥75 years), diabetes mellitus, stroke (2 points), vascular disease, age (≥65 years), sex category (female) score of 2.8. There was no significant decline in the adjusted 1-year all-cause mortality between the first and last years of the study period (adjusted mortality: FY 2007, 8.0%; FY 2015, 7.8%; P for trend=0.68). Noncardiovascular death accounted for 61% of all deaths; the adjusted 1-year noncardiovascular mortality rate rose from 4.5% in FY 2007 to 5.2% in FY 2015 (P for trend=0.007). In contrast, the 1-year cardiovascular mortality rate decreased from 3.5% in FY 2007 to 2.6% in FY 2015 (P for trend=0.01). CONCLUSIONS Overall 1-year all-cause mortality in individuals with incident atrial fibrillation has not improved despite a significant reduction in the rate of cardiovascular death. These findings highlight the importance of recognizing and managing concomitant noncardiovascular conditions in patients with atrial fibrillation.



J Am Heart Assoc: 19 Oct 2020; 9:e016810
Singh SM, Abdel-Qadir H, Pang A, Fang J, ... Wijeysundera HC, Ko DT
J Am Heart Assoc: 19 Oct 2020; 9:e016810 | PMID: 32924719
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Abstract

Unmasking Arrhythmogenic Hubs of Reentry Driving Persistent Atrial Fibrillation for Patient-Specific Treatment.

Hansen BJ, Zhao J, Helfrich KM, Li N, ... Hummel JD, Fedorov VV

Background Atrial fibrillation (AF) driver mechanisms are obscured to clinical multielectrode mapping approaches that provide partial, surface-only visualization of unstable 3-dimensional atrial conduction. We hypothesized that transient modulation of refractoriness by pharmacologic challenge during multielectrode mapping improves visualization of hidden paths of reentrant AF drivers for targeted ablation. Methods and Results Pharmacologic challenge with adenosine was tested in ex vivo human hearts with a history of AF and cardiac diseases by multielectrode and high-resolution subsurface near-infrared optical mapping, integrated with 3-dimensional structural imaging and heart-specific computational simulations. Adenosine challenge was also studied on acutely terminated AF drivers in 10 patients with persistent AF. Ex vivo, adenosine stabilized reentrant driver paths within arrhythmogenic fibrotic hubs and improved visualization of reentrant paths, previously seen as focal or unstable breakthrough activation pattern, for targeted AF ablation. Computational simulations suggested that shortening of atrial refractoriness by adenosine may (1) improve driver stability by annihilating spatially unstable functional blocks and tightening reentrant circuits around fibrotic substrates, thus unmasking the common reentrant path; and (2) destabilize already stable reentrant drivers along fibrotic substrates by accelerating competing fibrillatory wavelets or secondary drivers. In patients with persistent AF, adenosine challenge unmasked hidden common reentry paths (9/15 AF drivers, 41±26% to 68±25% visualization), but worsened visualization of previously visible reentry paths (6/15, 74±14% to 34±12%). AF driver ablation led to acute termination of AF. Conclusions Our ex vivo to in vivo human translational study suggests that transiently altering atrial refractoriness can stabilize reentrant paths and unmask arrhythmogenic hubs to guide targeted AF driver ablation treatment.



J Am Heart Assoc: 19 Oct 2020; 9:e017789
Hansen BJ, Zhao J, Helfrich KM, Li N, ... Hummel JD, Fedorov VV
J Am Heart Assoc: 19 Oct 2020; 9:e017789 | PMID: 33006292
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Abstract

Computerized Analysis of the Ventricular Fibrillation Waveform Allows Identification of Myocardial Infarction: A Proof-of-Concept Study for Smart Defibrillator Applications in Cardiac Arrest.

Thannhauser J, Nas J, Rebergen DJ, Westra SW, ... Bonnes JL, Brouwer MA

Background In cardiac arrest, computerized analysis of the ventricular fibrillation (VF) waveform provides prognostic information, while its diagnostic potential is subject of study. Animal studies suggest that VF morphology is affected by prior myocardial infarction (MI), and even more by acute MI. This experimental in-human study reports on the discriminative value of VF waveform analysis to identify a prior MI. Outcomes may provide support for in-field studies on acute MI. Methods and Results We conducted a prospective registry of implantable cardioverter defibrillator recipients with defibrillation testing (2010-2014). From 12-lead surface ECG VF recordings, we calculated 10 VF waveform characteristics. First, we studied detection of prior MI with lead II, using one key VF characteristic (amplitude spectrum area [AMSA]). Subsequently, we constructed diagnostic machine learning models: model A, lead II, all VF characteristics; model B, 12-lead, AMSA only; and model C, 12-lead, all VF characteristics. Prior MI was present in 58% (119/206) of patients. The approach using the AMSA of lead II demonstrated a C-statistic of 0.61 (95% CI, 0.54-0.68). Model A performance was not significantly better: 0.66 (95% CI, 0.59-0.73), =0.09 versus AMSA lead II. Model B yielded a higher C-statistic: 0.75 (95% CI, 0.68-0.81), <0.001 versus AMSA lead II. Model C did not improve this further: 0.74 (95% CI, 0.67-0.80), =0.66 versus model B. Conclusions This proof-of-concept study provides the first in-human evidence that MI detection seems feasible using VF waveform analysis. Information from multiple ECG leads rather than from multiple VF characteristics may improve diagnostic accuracy. These results require additional experimental studies and may serve as pilot data for in-field smart defibrillator studies, to try and identify acute MI in the earliest stages of cardiac arrest.



J Am Heart Assoc: 19 Oct 2020; 9:e016727
Thannhauser J, Nas J, Rebergen DJ, Westra SW, ... Bonnes JL, Brouwer MA
J Am Heart Assoc: 19 Oct 2020; 9:e016727 | PMID: 33003984
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Abstract

New Predictor of Very Late Recurrence After Catheter Ablation of Atrial Fibrillation Using Holter Electrocardiogram Parameters.

Egami Y, Ukita K, Kawamura A, Nakamura H, ... Nishino M, Tanouchi J

This study aimed to evaluate the predictors of very late recurrence of atrial fibrillation (VLRAF) after an initial AF catheter ablation (CA) by analyzing the follow-up Holter electrocardiogram. We retrospectively studied patients (n = 253, mean age: 66 years, woman: 30%, paroxysmal AF: 73%) without recurrence of AF within 12 months and the use of antiarrhythmic drugs. In the Holter electrocardiogram analysis, the atrial premature complexes (APCs) burden, the profile of the APCs run and prematurity index of the APCs were evaluated. Fifty-one patients (20%) had VLRAF during the follow-up period (mean follow up: 46 months). Patients with VLRAF had a significantly greater APCs burden (0.318% [0.084 to 1.405] vs 0.132% [0.051 to 0.461], p = 0.022), longer number of APCs run (5 [3 to 11] vs 4 [0 to 7], p = 0.019), and shorter minimum prematurity index of the APCs (47 ± 7 vs 51 ± 6, p = 0.001) than those without VLRAF. The optimal cutoff value for the APCs burden, maximum number of APCs run, and minimum prematurity index of the APCs to predict VLRAF was 0.159%, 10, and 48%, respectively. The minimum prematurity index of the APCs (≤48%) was significantly associated with VLRAF in the multivariate analysis. In conclusion, the minimum prematurity index of the APCs (≤48%) at 12 months after CA was shown to be an independent predictor of VLRAF in patients without antiarrhythmic drugs. Although the index is a very simple parameter automatically calculated by analysis software, it can be an important index for following patients after CA over the long-term.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Oct 2020; 133:71-76
Egami Y, Ukita K, Kawamura A, Nakamura H, ... Nishino M, Tanouchi J
Am J Cardiol: 14 Oct 2020; 133:71-76 | PMID: 32811653
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Abstract

Atrial fibrillation and the risk of ischaemic strokes or intracranial haemorrhages: comparisons of the catheter ablation, medical therapy, and non-atrial fibrillation population.

Kim M, Yu HT, Kim J, Kim TH, ... Lee MH, Pak HN
Aims 
Although atrial fibrillation (AF) catheter ablation (AFCA) is an effective rhythm control strategy, there is limited data on whether ischaemic stroke (IS) or intracranial haemorrhage (ICH) decreases after AFCA compared with medical therapy or non-AF population. We explored the IS and ICH risk after AFCA or medical therapy in the AF population and matched non-AF population.
Methods and results 
We compared 1629 patients with AFCA (Yonsei AF ablation cohort), 3258 with medical therapy [Korean National Health Insurance (NHIS) database], and 3258 non-AF subjects (NHIS database) following a 1:2:2 propensity score matching. All AFCA patients underwent regular rhythm follow-ups for 51 ± 29 months. Among the AFCA group, the incidence rate ratio (IRR) of ISs was significantly higher in patients with sustained AF recurrences after the last ablation (0.87%) than in those remaining in sinus rhythm (0.24%, P = 0.017; log rank P = 0.003). The IRR of ISs was significantly higher in the medical therapy (1.09%) than AFCA (0.30%, P < 0.001, log rank P < 0.001 vs. medical therapy) or non-AF groups (0.34%, P < 0.001, log rank P < 0.001 vs. medical therapy; P = 0.673, log rank P = 0.874 vs. AFCA). The IRR of ICHs was 0.17% in the medical therapy, 0.06% in the AFCA (P = 0.023, log rank P = 0.042 vs. medical therapy), and 0.12% in the non-AF group (P = 0.226, log rank P = 0.241 vs. medical therapy; P = 0.172, log rank P = 0.193 vs. AFCA).
Conclusion 
Post-procedural AF control influences the risk of ISs. Atrial fibrillation catheter ablation significantly reduces the risk of both ISs and ICHs to the extent of the non-AF population compared to the medical therapy.

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

Europace: 11 Oct 2020; epub ahead of print
Kim M, Yu HT, Kim J, Kim TH, ... Lee MH, Pak HN
Europace: 11 Oct 2020; epub ahead of print | PMID: 33045047
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Abstract

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

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

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

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

Changes in quality of life, cognition and functional status following catheter ablation of atrial fibrillation.

Piccini JP, Todd DM, Massaro T, Lougee A, ... Di Biase L, Kirchhof P
Objective
To investigate changes in quality of life (QoL), cognition and functional status according to arrhythmia recurrence after atrial fibrillation (AF) ablation.
Methods
We compared QoL, cognition and functional status in patients with recurrent atrial tachycardia (AT)/AF versus those without recurrent AT/AF in the AXAFA-AFNET 5 clinical trial. We also sought to identify factors associated with improvement in QoL and functional status following AF ablation by overall change scores with and without analysis of covariance (ANCOVA).
Results
Among 518 patients who underwent AF ablation, 154 (29.7%) experienced recurrent AT/AF at 3 months. Patients with recurrent AT/AF had higher mean CHADS-VASc scores (2.8 vs 2.3, p<0.001) and more persistent forms of AF (51 vs 39%, p=0.012). Median changes in the SF-12 physical (3 (25th, 75th: -1, 8) vs 1 (-5, 8), p=0.026) and mental scores (2 (-3, 9) vs 0 (-4, 5), p=0.004), EQ-5D (0 (0,2) vs 0 (-0.1, 0.1), p=0.027) and Karnofsky functional status scores (10 (0, 10) vs 0 (0, 10), p=0.001) were more favourable in patients without recurrent AT/AF. In the overall cohort, the proportion with at least mild cognitive impairment (Montreal Cognitive Assessment <26) declined from 30.3% (n=157) at baseline to 21.8% (n=113) at follow-up. ANCOVA identified greater improvement in Karnofsky functional status (p<0.001) but not SF-12 physical (p=0.238) or mental scores (p=0.065) in those without recurrent AT/AF compared with patients with recurrent AT/AF.
Conclusions
Patients without recurrent AT/AF appear to experience greater improvement in functional status but similar QoL as those with recurrent AT/AF after AF ablation.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.

Heart: 11 Oct 2020; epub ahead of print
Piccini JP, Todd DM, Massaro T, Lougee A, ... Di Biase L, Kirchhof P
Heart: 11 Oct 2020; epub ahead of print | PMID: 33046527
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Abstract

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Idiopathic ventricular fibrillation: the ongoing quest for diagnostic refinement.

Conte G, Giudicessi JR, Ackerman MJ

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

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

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

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

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

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

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

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

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

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

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

Left atrial appendage closure versus medical therapy in patients with atrial fibrillation: the APPLY study.

Gloekler S, Fürholz M, de Marchi S, Kleinecke C, ... Windecker S, Meier B
Aims
Left atrial appendage closure (LAAC) with AMPLATZER occluders is used for stroke prevention in atrial fibrillation (AF). Net clinical benefit compared to medical therapy has not been tested. The aim of this study was to test whether long-term clinical outcome after LAAC with AMPLATZER occluders may be similar to medical therapy.
Methods and results
Five hundred consecutive patients who underwent LAAC with AMPLATZER occluders were compared to 500 patients with medical therapy by propensity score matching. The primary efficacy endpoint was a composite of stroke, systemic embolism and cardiovascular/unexplained death. The primary safety endpoint consisted of major procedural adverse events and major bleedings. For assessment of net clinical benefit, all of the above-mentioned hazards were combined. After 2,645 patient-years at a mean follow-up of 2.7±1.5 years, the primary efficacy endpoint was reached by 75/1,342, 5.6% in the LAAC group versus 102/1,303, 7.8% per 100 patient-years (hazard ratio [HR] 0.70, 95% confidence interval [CI]: 0.53-0.95, p=0.026). The primary safety endpoint occurred in 48/1,342, 3.6% versus 60/1,303, 4.6% per 100 patient-years (HR 0.80, 95% CI: 0.55-1.18, p=0.21), and the combined hazard endpoint in 109/1,342, 8.1% versus 142/1,303, 10.9% per 100 patient-years (HR 0.76, 95% CI: 0.60-0.97, p=0.018). Patients receiving LAAC demonstrated lower rates of both all-cause and cardiovascular mortality (111/1,342, 8.3% vs 151/1,303, 11.6% per 100 patient-years [HR 0.72, 95% CI: 0.56-0.92, p=0.005] and 54/1,342, 4.0% vs 84/1,303, 6.5% per 100 patient-years [HR 0.64, 95% CI: 0.46-0.89, p=0.007]).
Conclusions
LAAC with AMPLATZER devices showed a net clinical benefit over medical therapy by superior efficacy, similar safety and a benefit in all-cause and cardiovascular mortality.



EuroIntervention: 08 Oct 2020; 16:e767-774
Gloekler S, Fürholz M, de Marchi S, Kleinecke C, ... Windecker S, Meier B
EuroIntervention: 08 Oct 2020; 16:e767-774 | PMID: 32583806
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Impact:
Abstract

A randomized clinical trial to evaluate the efficacy and safety of rivaroxaban in patients with bioprosthetic mitral valve and atrial fibrillation or flutter: Rationale and design of the RIVER trial.

Guimarães HP, de Barros E Silva PGM, Liporace IL, Sampaio RO, ... Berwanger O,
Background
The efficacy and safety of rivaroxaban in patients with bioprosthetic mitral valves and atrial fibrillation or flutter remain uncertain.
Design
RIVER was an academic-led, multicenter, open-label, randomized, non-inferiority trial with blinded outcome adjudication that enrolled 1005 patients from 49 sites in Brazil. Patients with a bioprosthetic mitral valve and atrial fibrillation or flutter were randomly assigned (1:1) to rivaroxaban 20mg once daily (15mg in those with creatinine clearance <50mL/min) or dose-adjusted warfarin (target international normalized ratio 2.0-30.); the follow-up period was 12months. The primary outcome was a composite of all-cause mortality, stroke, transient ischemic attack, major bleeding, valve thrombosis, systemic embolism, or hospitalization for heart failure. Secondary outcomes included individual components of the primary composite outcome, bleeding events, and venous thromboembolism.
Summary
RIVER represents the largest trial specifically designed to assess the efficacy and safety of a direct oral anticoagulant in patients with bioprosthetic mitral valves and atrial fibrillation or flutter. The results of this trial can inform clinical practice and international guidelines.

Copyright © 2020. Published by Elsevier Inc.

Am Heart J: 08 Oct 2020; epub ahead of print
Guimarães HP, de Barros E Silva PGM, Liporace IL, Sampaio RO, ... Berwanger O,
Am Heart J: 08 Oct 2020; epub ahead of print | PMID: 33045224
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Impact:
Abstract

Combined Epicardial and Endocardial Ablation for Atrial Fibrillation: Best Practices and Guide to Hybrid Convergent Procedures.

Makati KJ, Sood N, Lee LS, Yang F, ... Tondo C, Steinberg JS

The absence of strategies to consistently and effectively address non-paroxysmal atrial fibrillation (AF) by nonpharmacologic interventions has represented a longstanding treatment gap. A combined epicardial/endocardial ablation strategy, the hybrid Convergent procedure, was developed in response to this clinical need. A subxiphoid incision is used to access the pericardial space facilitating an epicardial ablation directed at isolation of the posterior wall of the left atrium. This is followed by an endocardial ablation to complete isolation of the pulmonary veins and for additional ablation as needed. Experience gained with the hybrid Convergent procedure during the last decade has led to the development and adoption of strategies to optimize the technique and mitigate risks. Additionally, a surgical and electrophysiology \"team\" approach including comprehensive training is believed critical to successfully develop the hybrid Convergent program. A recently completed randomized clinical trial indicated that this ablation strategy is superior to an endocardial only approach for patients with persistent AF. In this review, we propose and describe best practice guidelines for hybrid Convergent ablation based on a combination of published data, author consensus, and expert opinion. A summary of clinical outcomes, emerging evidence, and future perspectives are also discussed.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 08 Oct 2020; epub ahead of print
Makati KJ, Sood N, Lee LS, Yang F, ... Tondo C, Steinberg JS
Heart Rhythm: 08 Oct 2020; epub ahead of print | PMID: 33045430
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Impact:
Abstract

Magnetic Resonance Imaging-Guided Fibrosis Ablation for the Treatment of Atrial Fibrillation: The ALICIA Trial.

Bisbal F, Benito E, Teis A, Alarcón F, ... Bayés-Genis A, Mont L

Myocardial fibrosis is key for atrial fibrillation (AF) maintenance. We aimed to test the efficacy of ablating cardiac magnetic resonance (CMR)-detected atrial fibrosis plus pulmonary vein isolation (PVI).- This was an open label, parallel-group, randomized, controlled trial. Patients with symptomatic drug-refractory AF (paroxysmal and persistent) undergoing first or repeat ablation were randomized in a 1:1 basis to receive PVI plus CMR-guided fibrosis ablation (CMR group) or PVI alone (PVI-alone group). The primary endpoint was the rate of recurrence (>30 seconds) at 12 months of follow-up using a 12-lead ECG and Holter monitoring at 3, 6, and 12 months. The analysis was conducted by intention-to-treat.- In total, 155 patients (71% male, age 59±10, CHA2DS2-VASc 1.3±1.1, 54% Paroxysmal AF) were allocated to the PVI-alone group (N=76) or CMR group (N=79). First ablation was performed in 80% and 71% of patients in the PVI-alone and CMR groups, respectively. The mean atrial fibrosis burden was 12% (only 〜50% of patients had fibrosis outside the pulmonary vein area). 100% and 99% of patients received the assigned intervention in the PVI-alone and CMR group, respectively. The primary outcome was achieved in 21 patients (27.6%) in the PVI-alone group and 22 patients (27.8%) in the CMR group (odds ratio[OR]: 1.01, 95% confidence interval [CI] 0.50-2.04; p=0.976). There were no differences in the rate of adverse events (3 in the CMR group and 2 in the PVI-alone group; p=0.68).- A pragmatic ablation approach targeting CMR-detected atrial fibrosis plus PVI was not more effective than PVI alone in an unselected population undergoing AF ablation with low fibrosis burden.



Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print
Bisbal F, Benito E, Teis A, Alarcón F, ... Bayés-Genis A, Mont L
Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print | PMID: 33031713
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Impact:
Abstract

A Cross-Center Virtual Education Fellowship Program for Early-Career Researchers in Atrial Fibrillation.

Ajayi TB, Remein CD, Stafford RS, Fagerlin A, ... Childs E, Benjamin EJ

- It is estimated that over 46 million individuals have atrial fibrillation (AF) worldwide, and the incidence and prevalence of AF are increasing globally. There is an urgent need to accelerate the academic development of scientists possessing the skills to conduct innovative, collaborative AF research.- We designed and implemented a virtual AF Strategically Focused Research Network (SFRN) Cross-Center Fellowship program to enhance the competencies of early-stage AF basic, clinical, and population health researchers through experiential education and mentorship. The pedagogical model involves significant cross-Center collaboration to produce a curriculum focused on enhancing AF scientific competencies, fostering career/professional development, and cultivating grant writing skills. Outcomes for success involve clear expectations for fellows to produce manuscripts, presentations, and-for those at the appropriate career stage-grant applications. We evaluated the effectiveness of the fellowship model via mixed methods formative and summative surveys.- In two years of the fellowship, fellows generally achieved the productivity metrics sought by our pedagogical model, with outcomes for the twelve fellows including 50 AF-related manuscripts, 7 publications, 28 presentations, and 3 grant awards applications. Participant evaluations reported that the fellowship effectively met its educational objectives. All fellows reported medium to high satisfaction with the overall fellowship, webinar content and facilitation, staff communication and support, and program organization.- The fellowship model represents an innovative educational strategy by providing a virtual AF training and mentoring curriculum for early-career basic, clinical, and population health scientists working across multiple institutions, which is particularly valuable in the pandemic era.



Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print
Ajayi TB, Remein CD, Stafford RS, Fagerlin A, ... Childs E, Benjamin EJ
Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print | PMID: 33031707
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Impact:
Abstract

Histopathologic and Ultrastructural Findings in Human Myocardium after Stereotactic Body Radiation Therapy for Recalcitrant Ventricular Tachycardia.

Kiani S, Kutob L, Schneider F, Higgins KA, Lloyd MS

- Stereotactic body radiation therapy (SBRT) is a novel treatment for refractory ventricular tachycardia (VT). While outcomes have been described in small studies, histological findings after SBRT for VT are unknown.- We identified four explanted hearts in the context of transplant who received prior SBRT as part of an 11-patient compassionate use series at our institution. Clinical VTs and CT-defined target volume areas of SBRT were correlated to the anatomic specimens. Gross pathologic, histologic and ultrastructural examination of tissue in the target area of SBRT were performed.- All four patients had NICM, and three had left ventricular assist devices. In all cases, patients had recurrent sustained VT and had failed multiple antiarrhythmics and radiofrequency ablations. Four patients underwent 5 total SBRT therapy session with 25 Gy single fraction dose delivered to the area of culprit scar. The time from SBRT to explant ranged from 12-250 days. Histopathologic features following radiation were comparable in all patients and were characterized by areas of subendocardial necrosis surrounded by a rim of fibrosis. In one patient, the surrounding myocardium showed cytoplasmic vacuolization in myocytes and in another patchy interstitial fibrosis. Vascular changes consisted of myointimal thickening with prominence of endothelial cells. Electron microscopy (EM) of myocardium showed irregular, convoluted intercalated disc regions, loss of contractile elements with disrupted and haphazardly arranged myofibrils and edematous mitochondria with loss of cisternae.- Here, we report the first series of findings in human tissue in four patients after SBRT. Histopathologic features were consistent across all four patients, and were indicative of cell injury, death, and to a lesser extent, fibrosis. EM demonstrated features consistent with acute injury. These specimens provide radiobiological mechanisms of acute cellular injury during SBRT for VT which may have an antiarrhythmic effect prior to the onset of fibrosis.



Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print
Kiani S, Kutob L, Schneider F, Higgins KA, Lloyd MS
Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print | PMID: 33031001
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Impact:
Abstract

Social Media Influence Does Not Reflect Scholarly or Clinical Activity in Real Life.

Zenger B, Swink JM, Turner JL, Bunch TJ, ... Piccini JP, Steinberg BA

- Social media has become a major source of communication in medicine. We aimed to understand the relationship between physicians\' social media influence and their scholarly and clinical activity.- We identified attending, US electrophysiologists on Twitter. We compared physician Twitter activity to (a) scholarly publication record (h-index) and (b) clinical volume according to CMS. The ratio of observed vs. expected Twitter followers (obs/exp) was calculated based on each scholarly (K-index) and clinical activity.- We identified 284 physicians, with mean Twitter age of 5.0 (SD 3.1) years and median 568 followers (25, 75: 195, 1146). They had a median 34.5 peer-reviewed papers (25, 75: 14, 105), 401 citations (25, 75: 102, 1677), and h-index 9 (25, 75: 4, 19.8). The median K-index was 0.4 (25, 75: 0.15, 1.0), ranging 0.0008 - 29.2. The median EP procedures was 77 (25, 75: 0, 160) and E&M visits 264 (25, 75: 59, 516) in 2017. The top 1% electrophysiologists for followers accounted for 20% of all followers, 17% of status updates, had a mean h-index of 6 (vs. 15 for others, p=0.3), and accounted for 1% of procedural and E&M volumes. They had a mean K-index of 21 (vs. 0.77 for others, p<0.0001), and clinical obs/exp follower ratio of 17.9 and 18.1 for procedures and E&M (p<0.001 each, vs. others [0.81 for each]).- Electrophysiologists are active on Twitter, with modest influence often representative of scholarly and clinical activity. However, the most influential physicians appear to have relatively modest scholarly and clinical activity.



Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print
Zenger B, Swink JM, Turner JL, Bunch TJ, ... Piccini JP, Steinberg BA
Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print | PMID: 33030380
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Impact:
Abstract

Risk of Ischemic Stroke in Patients With Atrial Fibrillation After Extracranial Hemorrhage.

Zhou E, Lord A, Boehme A, Henninger N, ... Elkind MSV, Yaghi S
Background and purpose
Anticoagulation therapy not only reduces the risk of ischemic stroke in atrial fibrillation (AF) but also predisposes patients to hemorrhagic complications. There is limited knowledge on the risk of first-ever ischemic stroke in patients with AF after extracranial hemorrhage (ECH).
Methods
We conducted a retrospective study using the California State Inpatient Database including all nonfederal hospital admissions in California from 2005 to 2011. The exposure variable was hospitalization with a diagnosis of ECH with a previous diagnosis of AF. The outcome variable was a subsequent hospitalization with acute ischemic stroke. We excluded patients with stroke before or at the time of ECH diagnosis. We calculated adjusted hazard ratios for ischemic stroke during follow-up and at 6-month intervals using Cox regression models adjusted for pertinent demographics and comorbidities. In subgroup analyses, subjects were stratified by primary ECH diagnosis, severity/type of ECH, age, CHADS-VASc score, or the presence/absence of a gastrointestinal or genitourinary cancer.
Results
We identified 764 257 patients with AF (mean age 75 years, 49% women) without a documented history of stroke. Of these, 98 647 (13%) had an ECH-associated hospitalization, and 22 748 patients (3%) developed an ischemic stroke during the study period. Compared to patients without ECH, subjects with ECH had ≈15% higher rate of ischemic stroke (overall adjusted hazard ratio, 1.15 [95% CI, 1.11-1.19]). The risk appeared to remain elevated for at least 18 months after the index ECH. In subgroup analyses, the risk was highest in subjects with a primary admission diagnosis of ECH, severe ECH, gastrointestinal-type ECH, with gastrointestinal or genitourinary cancer, and age ≥60 years.
Conclusions
Patients with AF hospitalized with ECH may have a slightly elevated risk for future ischemic stroke. Particular consideration should be given to the optimal balance between the benefits and risks of anticoagulation therapy and the use of nonanticoagulant alternatives, such as left atrial appendage closure in this vulnerable population.



Stroke: 07 Oct 2020:STROKEAHA120029959; epub ahead of print
Zhou E, Lord A, Boehme A, Henninger N, ... Elkind MSV, Yaghi S
Stroke: 07 Oct 2020:STROKEAHA120029959; epub ahead of print | PMID: 33028172
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Impact:
Abstract

Left Ventricular Enlargement, CRT Response and Impact of MultiPoint Pacing.

Varma N, Baker Ii J, Tomassoni G, Love CJ, ... Lee K, Corbisiero R

- Left ventricular (LV) epicardial pacing results in slowly propagating paced wavefronts. We postulated that this effect might limit cardiac resynchronization therapy (CRT) efficacy in patients with LV enlargement using conventional biventricular (BiV) pacing with single-site LV pacing, but be mitigated by LV stimulation from 2 widely spaced sites using MultiPoint™ Pacing (MPP-AS: anatomical separation ≥ 30mm). We tested this hypothesis in the multicenter randomized MPP IDE trial.- Following implant, quadripolar BiV pacing was activated in all patients (n=506). From 3 to 9 months postimplant, among patients with available baseline LV end-diastolic volume (LVEDV) measures, 188 received BiV pacing, and 43 received MPP-AS. Patients were dichotomized by median baseline LVEDV indexed to height (LVEDVI). Outcomes were measured by the clinical composite score (CCS, primary efficacy endpoint), quality of life (QOL), LV structural remodeling (↑EF>5% and ↓ESV 10%) and heart failure (HF) event/ cardiovascular death.- LVEDVI was 1.1 mL/cm. Baseline characteristics differed in patients with LVEDVI vs. LVEDVI. Among patients with LVEDVI, BiV was less efficacious compared to patients with LVEDVI (CCS 65% vs. 79%). In contrast, MPP-AS programming generated greater CCS response (92% vs. 65%, p=0.023) and improved QOL (-31.0±29.7 vs. -15.7±22.1, p=0.038) vs. BiV in patients with LVEDVI. Reverse remodeling trended better with MPP-AS programming. When LVEDVI, HF event rate increased following the 3-month randomization point (0.0150±0.1725 in LVEDVI vs. -0.0190±0.0808 in LVEDVI, p=0.012) in BiV, but no heart failure event occurred in patients with MPP-AS programming between 3 and 9 months in LVEDVI. All measured outcomes did not differ in patients receiving MPP-AS and BiV pacing with LVEDVI.- Conventional BiV pacing, even with a quadripolar lead, has reduced efficacy in patients with LV enlargement. However, in patients with larger hearts and programmed to MPP-AS the greatest response rate was observed.



Circ Arrhythm Electrophysiol: 06 Oct 2020; epub ahead of print
Varma N, Baker Ii J, Tomassoni G, Love CJ, ... Lee K, Corbisiero R
Circ Arrhythm Electrophysiol: 06 Oct 2020; epub ahead of print | PMID: 33028082
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Impact:
Abstract

Malignant Arrhythmias in Patients with COVID-19: Incidence, Mechanisms and Outcomes.

Turagam MK, Musikantow D, Goldman ME, Bassily-Marcus A, ... Kohli-Seth R, Reddy VY

- Patients with coronavirus disease 2019 (COVID-19) who develop cardiac injury are reported to experience higher rates of malignant cardiac arrhythmias. However, little is known about these arrhythmias - their frequency, the underlying mechanisms, and their impact on mortality.- We extracted data from a registry (NCT04358029) regarding consecutive inpatients with confirmed COVID-19, were receiving continuous telemetric ECG monitoring, and had a definitive disposition of hospital discharge or death. Between patients who died versus discharged, we compared a primary composite endpoint of cardiac arrest from ventricular tachycardia/fibrillation or bradyarrhythmias such as atrio-ventricular block.- Among 800 COVID-19 patients at Mount Sinai Hospital with definitive dispositions, 140 patients had telemetric monitoring and either died (52) or were discharged (88). The median (IQR) age was 61 years (48 - 74); 73% men; and ethnicity was Caucasian in 34%. Comorbidities included hypertension in 61%, coronary artery disease in 25%, ventricular arrhythmia history in 1.4%, and no significant comorbidities in 16%. Compared to discharged patients, those who died had elevated peak troponin I levels (0.27 vs 0.02 ng/mL), and more primary endpoint events (17% vs 4%, p = 0.01), a difference driven by tachyarrhythmias. Fatal tachyarrhythmias invariably occurred in the presence of severe metabolic imbalance, while atrioventricular block was largely an independent primary event.- Hospitalized COVID-19 patients who die experience malignant cardiac arrhythmias more often than those surviving to discharge. However, these events represent a minority of cardiovascular deaths, and ventricular tachyarrhythmias are mainly associated with severe metabolic derangement.



Circ Arrhythm Electrophysiol: 06 Oct 2020; epub ahead of print
Turagam MK, Musikantow D, Goldman ME, Bassily-Marcus A, ... Kohli-Seth R, Reddy VY
Circ Arrhythm Electrophysiol: 06 Oct 2020; epub ahead of print | PMID: 33026892
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Impact:
Abstract

Screen-detected atrial fibrillation predicts mortality in elderly subjects.

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

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

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

Multiple Procedure Outcomes for Non-Paroxysmal Atrial Fibrillation: Left Atrial Posterior Wall Isolation versus Stepwise Ablation.

Barbhaiya CR, Knotts RJ, Beccarino N, Vargas-Pelaez AF, ... Aizer A, Chinitz LA
Objective
To compare multiple-procedure catheter ablation outcomes of a stepwise approach versus left atrial posterior wall isolation (LA PWI) in patients undergoing non-paroxysmal atrial fibrillation (NPAF) ablation.
Background
Unfavorable outcomes for stepwise ablation of NPAF in large clinical trials may be attributable to pro-arrhythmic effects of incomplete ablation lines. It is unknown if a more extensive initial ablation strategy results in improved outcomes following multiple ablation procedures.
Methods
222 consecutive patients with NPAF underwent first-time ablation using a contact-force sensing ablation catheter utilizing either a stepwise (Group 1, n=111) or LA PWI (Group 2, n=111) approach. The duration of follow-up was 36 months. The primary endpoint was freedom from atrial arrhythmia >30s. Secondary endpoints were freedom from persistent arrhythmia, repeat ablation, and recurrent arrhythmia after repeat ablation.
Results
There was similar freedom from atrial arrhythmias after index ablation for both stepwise and LA PWI groups at 36 months (60% vs. 69%, p=0.1). The stepwise group was more likely to present with persistent recurrent arrhythmia (29% vs 14%, p=0.005) and more likely to undergo second catheter ablation (32% vs. 12%, p<0.001) compared to LA PWI patients. Recurrent arrhythmia after repeat ablation was more likely in the stepwise group compared to the LA PWI group (15% vs 4%, p=0.003).
Conclusions
Compared to a stepwise approach, LA PWI for patients with NPAF resulted in a similar incidence of any atrial arrhythmia, lower incidence of persistent arrhythmia, and fewer repeat ablations. Results for repeat ablation were not improved with a more extensive initial approach. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print
Barbhaiya CR, Knotts RJ, Beccarino N, Vargas-Pelaez AF, ... Aizer A, Chinitz LA
J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33022816
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Impact:
Abstract

Healthcare Utilization and Cost in Patients with Atrial Fibrillation and Heart Failure Undergoing Catheter Ablation.

Field ME, Gold MR, Rahman M, Goldstein L, ... Piccini JP, Friedman DJ
Background
Catheter ablation is an effective treatment for patients with atrial fibrillation (AF) and heart failure (HF). However, little is known how healthcare utilization and cost change after ablation in this population. We sought to determine healthcare utilization and cost patterns among patients with AF and HF undergoing ablation.
Methods
Using a large US administrative database, we identified (n=1,568) treated with ablation with a primary and secondary diagnosis of AF and HF, respectively, were evaluated 1-year pre- and post-ablation for outcomes including inpatient admissions (AF or HF), emergency department (ED) visits, cardioversions, length of stay (LOS), and cost. A secondary analysis was extended to 3-years post-ablation.
Results
Reductions were observed in AF-related admissions (64%), LOS (65%), cardioversions (52%), ED visits (51%, all values, p<0.0001), and HF-related admissions (22%, p=0.01). There was a 40% reduction in inpatient admission cost ($4,165 pre-ablation to $2,510 post-ablation, p<0.0001). In a sensitivity analysis excluding repeat-ablation patients, greater reduction in overall AF management cost was observed compared to the full cohort (-43% vs -2%). Comparing 1-year pre- to 3-years post-ablation, both total mean AF-management cost ($850 per-patient per-month 1-year pre- to $546 3-years post-ablation, p<0.0001) and AF-related healthcare utilization was reduced.
Conclusions
Catheter ablation in patients with AF and HF resulted in significant reductions in healthcare utilization and cost through 3-years of follow-up. This reduction was observed regardless of whether repeat ablation was performed, reflecting positive impact of ablation on longer-term cost reduction. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print
Field ME, Gold MR, Rahman M, Goldstein L, ... Piccini JP, Friedman DJ
J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33022815
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Impact:
Abstract

Supraventricular Tachycardia in Patients with Coronary Sinus Stenosis/Atresia: Prevalence, Anatomical Features, and Ablation Outcomes.

Weng S, Tang M, Zhou B, Yu F, ... Fang P, Zhang S
Background
Supraventricular tachycardia (SVT) with coronary sinus (CS) ostial atresia (CSA) or CS stenosis (CSS) causes difficulty in electrophysiological procedures, but its characteristics are poorly understood.
Objective
Study the anatomical and clinical features of SVT patients with CSA/CSS.
Methods
Of 6,128 SVT patients undergoing electrophysiological procedures, consecutive patients with CSA/CSS were enrolled, and the baseline characteristics, imaging materials, intraoperative data, and follow-up outcomes were analyzed.
Results
Thirteen patients, 7 with CSA and 6 with CSS, underwent the electrophysiological procedure. Decapolar catheters were placed into the proximal CS in 3 cases, while the rest were placed at the free-wall of the right atrium. Fourteen arrhythmias were confirmed: 4 atrioventricular nodal reentrant tachycardias, 5 left-sided accessory pathways, 3 paroxysmal atrial fibrillations, and 2 atrial flutters. In addition to 3 patients who underwent only an electrophysiological study, the acute ablation success rate was 100% in 10 cases, with no procedure-related complications. After a median follow-up period of 59.6 months, only 1 case of atypical atrial flutter recurred. For those cases (7 CSA and 2 CSS) with a total of 10 anomalous types of CS drainage, three types were classified: from the CS to the persistent left superior vena cava (n=3), from an unroofed CS (n=3), and from the CS to the small cardiac vein (n=3) or Thebesian vein (n=1).
Conclusion
Patients with CSA/CSS may develop different kinds of SVT. Electrophysiological procedures for such patients are feasible and effective. An individualized mapping strategy based on the three types of CS drainage will be helpful. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print
Weng S, Tang M, Zhou B, Yu F, ... Fang P, Zhang S
J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33022772
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Impact:
Abstract

Clinical and Cardiac Characteristics of COVID-19 Mortalities in a Diverse New York City Cohort.

Abrams MP, Wan EY, Waase MP, Morrow JP, ... Garan H, Saluja D
Introduction
Electrocardiographic characteristics in COVID-19 related mortality have not yet been reported, particularly in racial/ethnic minorities.
Methods and results
We reviewed demographics, laboratory and cardiac tests, medications, and cardiac rhythm proximate to death or initiation of comfort care for patients hospitalized with a positive SARS-CoV-2 RT-PCR in 3 New York City hospitals between March 1 and April 3, 2020 who died. We described clinical characteristics and compared factors contributing toward arrhythmic versus non-arrhythmic death. Of 1258 patients screened, 133 died and were enrolled. Of these, 55.6% (74/133) were male, 69.9% (93/133) were racial/ethnic minorities, and 88.0% (117/133) had cardiovascular disease (CVD). The last cardiac rhythm recorded was ventricular tachycardia or fibrillation in 5.3% (7/133), pulseless electrical activity in 7.5% (10/133), unspecified bradycardia in 0.8% (1/133), and asystole in 26.3% (35/133). Most 74.4% (99/133) died receiving comfort measures only. The most common abnormalities on admission electrocardiogram included abnormal QRS axis (25.8%), atrial fibrillation/flutter (14.3%), atrial ectopy (12.0%), and right bundle branch block (11.9%). During hospitalization, an additional 17.6% developed atrial ectopy, 14.7% ventricular ectopy, 10.1% atrial fibrillation/flutter, and 7.8% a right ventricular abnormality. Arrhythmic death was confirmed or suspected in 8.3% (11/133) associated with age, coronary artery disease, asthma, vasopressor use, longer admission corrected QT interval, and left bundle branch block (LBBB).
Conclusions
Conduction, rhythm, and electrocardiographic abnormalities were common during COVID-19 related hospitalization. Arrhythmic death was associated with age, coronary artery disease, asthma, longer admission corrected QT interval, LBBB, ventricular ectopy, and usage of vasopressors. Most died receiving comfort measures. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print
Abrams MP, Wan EY, Waase MP, Morrow JP, ... Garan H, Saluja D
J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33022765
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Impact:
Abstract

Impact of individual stroke risk on outcome after Amplatzer left atrial appendage closure in patients with atrial fibrillation.

Häner JD, Fürholz M, Kleinecke C, Galea R, ... Meier B, Gloekler S
Objectives
To investigate periprocedural and long-term outcome of left atrial appendage closure (LAAC) using Amplatzer occluders with respect to individual pre-procedural stroke risk.
Background
LAAC is a proven strategy for prevention from stroke and bleeding in patients with nonvalvular atrial fibrillation not amenable to oral anticoagulation. Whether individual pre-procedural stroke risk may affect procedural and long-term clinical outcome after LAAC is unclear.
Methods
Multicenter study of consecutive patients who underwent Amplatzer-LAAC. Using pre-procedural CHADS score, outcomes were compared between a low (0-2 points) and a high stroke risk group (3-6 points).
Results
Five hundred consecutive patients (73.9 ± 10.1 years) who underwent Amplatzer-LAAC. Two hundred and forty eight had preprocedural CHADS score ≤ 2 points (low-risk group) and the remaining 252 patients had 3-6 points (high-risk group). Periprocedural complication rates (6.0% vs. 5.6%, p = .85), procedural success (LAAC without major periprocedural or device-related complications or major para-device leaks: 89.4% vs. 87.9%, p = .74), and 30-day-mortality (2.4% vs. 2.6%, p = .77) were comparable. After 1,346 patient-years (PY), the long-term composite efficacy endpoint (stroke, systemic embolism, cardiovascular, and unexplained death) was reached in 23/653 (3.5/100 PY) versus 52/693 (7.5/100 PY); HR = 2.13; 95%-CI, 1.28-3.65, p = .002) with stroke rates 67% and 68% lower than anticipated by preprocedural CHADS score. Combined safety endpoint (major periprocedural complications and major, life-threatening or fatal bleedings) occurred in 22/653 (3.4/100 PY) versus 28/693 (4.0/100 PY); HR = 1.20; 95%-CI, 0.66-2.20, p = .52).
Conclusions
Compared with patients at low risk of stroke, LAAC with Amplatzer devices is associated with similar safety and efficacy in high-risk patients in our study.

© 2020 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 05 Oct 2020; epub ahead of print
Häner JD, Fürholz M, Kleinecke C, Galea R, ... Meier B, Gloekler S
Catheter Cardiovasc Interv: 05 Oct 2020; epub ahead of print | PMID: 33022121
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Impact:
Abstract

Less dementia after catheter ablation for atrial fibrillation: a nationwide cohort study.

Kim D, Yang PS, Sung JH, Jang E, ... Lip GYH, Joung B
Aims
Accumulating evidence shows that atrial fibrillation (AF) is associated with an increased risk of dementia. Catheter ablation for AF prolongs the duration of sinus rhythm, thereby improving the quality of life. We investigated the association of catheter ablation for AF with the occurrence of dementia.
Methods and results
Using the Korean National Health Insurance Service database, among 194 928 adults with AF treated with ablation or medical therapy (antiarrhythmic or rate control drugs) between 1 January 2005 and 31 December 2015, we studied 9119 patients undergoing ablation and 17 978 patients managed with medical therapy. The time-at-risk was counted from the first medical therapy, and ablation was analysed as a time-varying exposure. Propensity score-matching was used to correct for differences between the groups. During a median follow-up of 52 months, compared with patients with medical therapy, ablated patients showed lower incidence and risk of overall dementia (8.1 and 5.6 per 1000 person-years, respectively; hazard ratio 0.73, 95% confidence interval 0.58-0.93). The associations between ablation and dementia risk were consistently observed after additionally censoring for incident stroke (hazard ratio 0.76, 95% confidence interval 0.61-0.95) and more pronounced in cases of ablation success whereas no significant differences observed in cases of ablation failure. Ablation was associated with lower risks of dementia subtypes including Alzheimer\'s disease and vascular dementia.
Conclusion
In this nationwide cohort of AF patients treated with catheter ablation or medical therapy, ablation was associated with decreased dementia risk. This relationship was evident after censoring for stroke and adjusting for clinical confounders.

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

Eur Heart J: 05 Oct 2020; epub ahead of print
Kim D, Yang PS, Sung JH, Jang E, ... Lip GYH, Joung B
Eur Heart J: 05 Oct 2020; epub ahead of print | PMID: 33022705
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Impact:
Abstract

3D Late Gadolinium Enhancement Cardiovascular Magnetic Resonance Predicts Inducibility of Ventricular Tachycardia in Adults with Repaired Tetralogy of Fallot.

Ghonim S, Ernst S, Keegan J, Giannakidis A, ... Gatzoulis MA, Babu-Narayan SV

- Adults with repaired tetralogy of Fallot (rTOF) die prematurely from ventricular tachycardia (VT) and sudden cardiac death. Inducible VT predicts mortality. Ventricular scar, the key substrate for VT, can be non-invasively defined with late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) but whether this relates to inducible VT is unknown.- Sixty-nine consecutive rTOF patients (43 male, mean 40{plus minus}15 years) clinically scheduled for invasive programmed VT-stimulation were prospectively recruited for prior 3D LGE CMR. Ventricular LGE was segmented and merged with reconstructed cardiac chambers and LGE volume measured.- VT was induced in 22(31%) patients. Univariable predictors of inducible VT included increased RV LGE (OR 1.15;p=0.001 per cm), increased non-apical vent LV LGE (OR 1.09;p=0.008 per cm), older age (OR 1.6;p=0.01 per decile), QRS duration ≥180ms (OR 3.5;p=0.02), history of non-sustained VT (OR 3.5; p=0.02) and previous clinical sustained VT (OR 12.8;p=0.003); only prior sustained VT (OR 8.02;p=0.02) remained independent in bivariable analyses after controlling for RV LGE volume (OR 1.14;p=0.003). An RV LGE volume of 25cm had 72% sensitivity and 81% specificity for predicting inducible VT (AUC 0.81;p<0.001). At the extreme cutoffs for \'ruling-out\' and \'ruling-in\' inducible VT, RV LGE >10cm was 100% sensitive and >36cm was 100% specific for predicting inducible VT.- 3D LGE CMR-defined scar burden is independently associated with inducible VT and may help refine patient selection for programmed VT-stimulation when applied to an at least intermediate clinical risk cohort.



Circ Arrhythm Electrophysiol: 05 Oct 2020; epub ahead of print
Ghonim S, Ernst S, Keegan J, Giannakidis A, ... Gatzoulis MA, Babu-Narayan SV
Circ Arrhythm Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33022183
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Impact:
Abstract

Digital Health and the Care of the Arrhythmia Patient; What Every Electrophysiologist Needs to Know.

Tarakji KG, Silva JNA, Chen LY, Turakhia MP, ... Wan EY, Chung MK

The field of cardiac electrophysiology has been on the cutting edge of advanced digital technologies for many years. More recently, medical device development through traditional clinical trials has been supplemented by direct to consumer products with advancement of wearables and healthcare apps. The rapid growth of innovation along with the mega-data generated has created challenges and opportunities. This review summarizes the regulatory landscape, applications to clinical practice, opportunities for virtual clinical trials, the use of artificial intelligence to streamline and interpret data, and integration into the electronic medical records and medical practice. Preparation of the new generation of physicians, guidance and promotion by professional societies, and advancement of research in the interpretation and application of big data and the impact of digital technologies on health outcomes will help to advance the adoption and the future of digital health care.



Circ Arrhythm Electrophysiol: 05 Oct 2020; epub ahead of print
Tarakji KG, Silva JNA, Chen LY, Turakhia MP, ... Wan EY, Chung MK
Circ Arrhythm Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33021815
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Impact:
Abstract

The Clinical Application of the Deep Learning Technique for Predicting Trigger Origins in Paroxysmal Atrial Fibrillation Patients with Catheter Ablation.

Liu CM, Chang SL, Chen HH, Chen WS, ... Lu HH, Chen SA

- Non-pulmonary vein (NPV) trigger has been reported as an important predictor of recurrence post-atrial fibrillation (AF) ablation. Elimination of NPV triggers can reduce the recurrence of post-ablation AF. Deep learning was applied to pre-ablation pulmonary vein computed tomography (PVCT) geometric slices to create a prediction model for NPV triggers in patients with paroxysmal atrial fibrillation (PAF).- We retrospectively analyzed 521 PAF patients who underwent catheter ablation of PAF. Among them, PVCT geometric slices from 358 non-recurrent AF patients (1-3 mm interspace per slice, 20-200 slices for each patient, ranging from the upper border of the left atrium to the bottom of the heart, for a total of 23683 images of slices) were used in the deep learning process, the ResNet34 of the neural network, to create the prediction model of the NPV trigger. There were 298 (83.2%) patients with only pulmonary vein (PV) triggers and 60 (16.8%) patients with NPV triggers +/- PV triggers. The patients were randomly assigned to either training, validation or test groups and their data was allocated according to those sets. The image datasets were split into training (n=17340), validation (n=3491), and testing (n=2852) groups, which had completely independent sets of patients.- The accuracy of prediction in each PVCT image for NPV trigger was up to 82.4±2.0%. The sensitivity and specificity were 64.3±5.4% and 88.4±1.9%, respectively. For each patient, the accuracy of prediction for a NPV trigger was 88.6±2.3%. The sensitivity and specificity were 75.0±5.8% and 95.7±1.8%, respectively. The area under the curve (AUC) for each image and patient were 0.82±0.01 and 0.88±0.07, respectively.- The deep learning model using pre-ablation PVCT can be applied to predict the trigger origins in PAF patients receiving catheter ablation. The application of this model may identify patients with a high risk of NPV trigger before ablation.



Circ Arrhythm Electrophysiol: 05 Oct 2020; epub ahead of print
Liu CM, Chang SL, Chen HH, Chen WS, ... Lu HH, Chen SA
Circ Arrhythm Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33021404
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Impact:
Abstract

Office, central and ambulatory blood pressure for predicting incident atrial fibrillation in older adults.

Matsumoto K, Jin Z, Homma S, Elkind MSV, ... Sacco RL, Di Tullio MR
Objectives
Recently, more sophisticated blood pressure (BP) measurements, such as central and ambulatory BP (ABP), have proven to be stronger predictors of future cardiovascular disease than conventional office BP. Their predictive value for atrial fibrillation development is not established. We investigated the prognostic impact for incident atrial fibrillation of office, central and ambulatory BP measurements in a predominantly older population-based cohort.
Methods
Of 1004 participants in the Cardiovascular Abnormalities and Brain Lesions (CABL) study, 769 in sinus rhythm with no history of atrial fibrillation or stroke (mean age 70.5 years) underwent ABP and arterial wave reflection analysis for central BP determination. Fine and Gray\'s proportional subdistribution hazards models were used to assess the association of BP parameters with incident atrial fibrillation.
Results
During 9.5 years, atrial fibrillation occurred in 83 participants. No office BP variable showed a significant association with incident atrial fibrillation. Central SBP and central pulse pressure were marginally associated with incident atrial fibrillation in multivariate analysis. Among ABP variables, 24-h SBP [adjusted hazard ratio per 10 mmHg, 1.24; 95% confidence interval (CI) 1.07--1.44; P = 0.004], daytime SBP (adjusted hazard ratio per 10 mmHg, 1.21; 95% CI 1.04--1.40; P = 0.011) and night-time SBP (adjusted hazard ratio per 10 mmHg, 1.22; 95% CI 1.07--1.39; P = 0.002) were significantly associated with incident atrial fibillation.
Conclusion
In a predominantly older, stroke-free community-based cohort, ABP was a better independent predictor of incident atrial fibrillation than central BP, whereas office BP was inadequate for this purpose.



J Hypertens: 05 Oct 2020; epub ahead of print
Matsumoto K, Jin Z, Homma S, Elkind MSV, ... Sacco RL, Di Tullio MR
J Hypertens: 05 Oct 2020; epub ahead of print | PMID: 33031165
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Impact:
Abstract

Implant, Performance, and Retrieval of an Atrial Leadless Pacemaker in Sheep.

Vatterott PJ, Eggen MD, Hilpisch KE, Drake RA, ... Mesich ML, Ramon LC
Background
Medtronic is developing an atrial Micra™ Transcatheter Pacing System and associated retrieval system.
Objective
To evaluate chronic atrial Micra retrieval, re-implant, and chronic pacing performance.
Methods
Sheep were implanted in two groups. Group 1 (G1, n=6) for six months, a second device implanted and first retrieved and studied an additional six months. Group 2 (G2, n=6) for six months, devices were retrieved, and a second device implanted and observed acutely. Both groups underwent histopathologic evaluation. Pacing capture threshold (PCT), p-waves, and pacing impedances were measured chronically. Device retrieval times recorded and intracardiac echo was used.
Results
At 24 weeks, PCTs for G1 were low and stable for both the first device (0.55±0.14V) and second device (0.57±0.09V) where average retrieval time was 17:35 minutes (min). For G2, average retrieval time was 6:12 min, chronic PCTs in the first device were (0.53±0.11V), and acute PCTs for the second device were 0.71±0.19V. Pathologic findings were within an expected range of tissue responses for similar Micra acute and chronic implants and device retrievals. P-waves and impedance were stable and within an expected range for implant site and electrode design. Complications included one early dislodgement and one death attributed to a prototype retrieval tool.
Conclusions
In an animal model an atrial Micra can be easily implanted with excellent chronic pacing performance and is easily retrievable at six months. A second device can successfully be implanted with low, chronic stable thresholds. A developed prototype retrieval tool was easy to use and, with modifications, complication free.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 05 Oct 2020; epub ahead of print
Vatterott PJ, Eggen MD, Hilpisch KE, Drake RA, ... Mesich ML, Ramon LC
Heart Rhythm: 05 Oct 2020; epub ahead of print | PMID: 33035647
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Impact:
Abstract

Outcomes and Mortality Associated with Atrial Arrhythmias Among Patients Hospitalized with COVID-19.

Peltzer B, Manocha KK, Ying X, Kirzner J, ... Goyal P, Cheung JW
Introduction
The impact of atrial arrhythmias on COVID-19-associated outcomes are unclear. We sought to identify prevalence, risk factors and outcomes associated with atrial arrhythmias among patients hospitalized with COVID-19.
Methods
An observational cohort study of 1053 patients with SARS-CoV2 infection admitted to a quaternary care hospital and a community hospital was conducted. Data from electrocardiographic and telemetry were collected to identify atrial fibrillation (AF) or atrial flutter/tachycardia (AFL). The association between atrial arrhythmias and 30-day mortality was assessed with multivariable analysis.
Results
Mean age of patients was 62 ± 17 years and 62% were men. Atrial arrhythmias were identified in 166 (15.8%) patients, with AF in 154 (14.6%) patients and AFL in 40 (3.8%) patients. Newly detected atrial arrhythmias occurred in 101 (9.6%) patients. Age, male sex, prior AF, renal disease, and hypoxia on presentation were independently associated with AF/AFL occurrence. Compared to patients without AF/AFL, patients with AF/AFL had significantly higher levels of troponin, B-type natriuretic peptide, C-reactive protein, ferritin and D-dimer. Mortality was significantly higher among patients with AF/AFL (39.2%) compared to patients without (13.4%; P<0.001). After adjustment for age and co-morbidities, AF/AFL (adjusted OR 1.93; P = 0.007) and newly detected AF/AFL (adjusted OR 2.87; P <0.001) were independently associated with 30-day mortality.
Conclusions
Atrial arrhythmias are common among patients hospitalized with COVID-19. The presence of AF/AFL tracked with markers of inflammation and cardiac injury. Atrial arrhythmias were independently associated with increased mortality. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 04 Oct 2020; epub ahead of print
Peltzer B, Manocha KK, Ying X, Kirzner J, ... Goyal P, Cheung JW
J Cardiovasc Electrophysiol: 04 Oct 2020; epub ahead of print | PMID: 33017083
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Abstract

A novel screening tool to unmask potential interference between S-ICD and left ventricular assist device.

Zormpas C, Eiringhaus J, Hillmann HAK, Hohmann S, ... Veltmann C, Duncker D
Introduction
In patients with a left ventricular assist device (LVAD), the subcutaneous ICD (S-ICD) can be an alternative to transvenous ICD systems due to reduced risk of systemic infection, which could lead to extraction of the ICD as well as the LVAD. S-ICD eligibility is lower in patients with LVAD than in patients with end-stage heart failure without LVAD. Several reports have shown inappropriate S-ICD therapy in the coexistence of LVAD and S-ICD. The aim of the present study was to evaluate S-ICD eligibility in patients with LVAD using the established ECG-based screening test as well as a novel device-based screening test in order to identify potentially inappropriate S-ICD sensing in this specific patient cohort.
Methods and results
The present study included 115 patients implanted with an LVAD. The standard ECG-based screening test and a novel device-based screening test were performed in all patients. Eighty patients (70%) were eligible for S-ICD therapy with the standard ECG-based screening test. Performance of the novel device-based screening test identified device-device interference in 14 of these 80 patients (12%).
Conclusion
Using a novel extended device-based S-ICD screening method, a small number of patients with LVAD deemed eligible for S-ICD with the standard ECG-based screening test exhibit device-device interference. Careful S-ICD screening should be performed in patients with LVAD, who are candidates for S-ICD therapy, in order to prevent inappropriate sensing or ICD therapy. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 04 Oct 2020; epub ahead of print
Zormpas C, Eiringhaus J, Hillmann HAK, Hohmann S, ... Veltmann C, Duncker D
J Cardiovasc Electrophysiol: 04 Oct 2020; epub ahead of print | PMID: 33017069
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Impact:
Abstract

Impact of atrial fibrillation on outcomes following MitraClip: A contemporary population-based analysis.

Saad AM, Kassis N, Gad MM, Abdelfattah O, ... Shekhar S, Kapadia SR
Objectives
Despite the rising use of MC, the impact of preexisting AF, a common comorbidity, on short-term postprocedural outcomes is poorly defined. We sought to assess outcomes between patients with and without atrial fibrillation (AF) who underwent percutaneous mitral valve repair with MitraClip (MC).
Methods
In this retrospective cohort study, the Nationwide Readmissions Database was queried for patients who underwent MC between 2014-2017. Groups were stratified based on the presence of AF. Multivariable logistic regression analyses were performed to identify the association between AF and in-hospital stroke and mortality.
Results
Of the 15,570 patients who underwent MC, 7,740 (49.7%) had AF. AF patients were older (82 vs. 79 years, p < .001) and more comorbid. Patients with AF relative to without AF demonstrated increased rates of in-hospital ischemic (1.3% vs .0.7%, p < .001) and hemorrhagic stroke (0.3% vs. 0.1%, p = .007), longer duration of hospitalization (median 3 vs. 2 days, p < .001), and similar in-hospital mortality (2.8% vs. 2.6%, p = .52). After adjusting for comorbidities, age, sex, hospital procedural volume, and CHA2DS2-VASc, the presence of AF was associated with higher in-hospital stroke (OR = 2.096, 95%CI[1.503-2.921], p < .001) but not in-hospital mortality (OR = 1.012, 95%CI[0.828-1.238], p = .904). AF patients were more likely to be readmitted (16.8% vs.14.1%, p < .001) and die (1.5% vs. 0.9%, p = .005) within 30 days of discharge despite similar incidences of stroke (0.7% vs. 0.6%, p = .53).
Conclusions
The increased risk of in-hospital stroke, 30-day mortality, and longer hospitalization suggest the need for increased preprocedural optimization by means of stroke prevention strategies in those with AF undergoing MC.

© 2020 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 04 Oct 2020; epub ahead of print
Saad AM, Kassis N, Gad MM, Abdelfattah O, ... Shekhar S, Kapadia SR
Catheter Cardiovasc Interv: 04 Oct 2020; epub ahead of print | PMID: 33016645
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Abstract

Risk Factors for Early Recurrence following Ablation for Accessory Pathways: The Role of Consolidation Lesions.

Dionne A, Gauvreau K, O\'Leary E, Mah DY, ... Triedman JK, Walsh EP

- Atrioventricular reentrant tachycardia is common in children. Catheter ablation is increasingly used as a first line therapy with a high acute success rate, but recurrence during follow-up remains a concern. The aim of this study was to identify risk factors for recurrence after accessory pathway (AP) ablation.- Retrospective cohort study including patients who underwent AP ablation between 2013-2018. Cox proportional hazards model were used to examine the association between patient and procedural characteristics and recurrence during follow-up.- From 558 AP ablation procedure, 542 (97%) were acutely successful. During a median follow-up of 0.4 [IQR 0.1, 1.4] years, there were 42 (8%) patients with documented recurrence. On univariate analysis, early recurrence was associated with younger age, congenital heart disease, multiple AP, AP location (right sided and postero-septal versus left sided), cryoablation (versus RF), empiric ablation, the lack of full power RF lesions (<50W), RF consolidation time < 90 seconds and the use of fluoroscopy without a 3-dimensional electroanatomic mapping system. On multivariable analysis, only multiple AP (HR 2.78 [95% CI 1.063, 4.74]) and RF consolidation time < 90 seconds (HR 4.38 [95% CI 1.92, 9.51]) remained significantly associated with early recurrence; this association remained true when analyzed in subgroups by pathway location for right and left free wall AP.- In our institutional experience, RF consolidation time < 90 seconds after ablation of AP was associated with an increased risk of early recurrence.



Circ Arrhythm Electrophysiol: 04 Oct 2020; epub ahead of print
Dionne A, Gauvreau K, O'Leary E, Mah DY, ... Triedman JK, Walsh EP
Circ Arrhythm Electrophysiol: 04 Oct 2020; epub ahead of print | PMID: 33017181
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Abstract

Comparative Effectiveness and Safety of Oral Anticoagulants Across Kidney Function in Patients With Atrial Fibrillation.

Yao X, Inselman JW, Ross JS, Izem R, ... Shah ND, Noseworthy PA

Background Patients with atrial fibrillation and severely decreased kidney function were excluded from the pivotal non-vitamin K antagonist oral anticoagulants (NOAC) trials, thereby raising questions about comparative safety and effectiveness in patients with reduced kidney function. The study aimed to compare oral anticoagulants across the range of kidney function in patients with atrial fibrillation. Methods and Results Using a US administrative claims database with linked laboratory data, 34 569 new users of oral anticoagulants with atrial fibrillation and estimated glomerular filtration rate ≥15 mL/(min·1.73 m) were identified between October 1, 2010 to November 29, 2017. The proportion of patients using NOACs declined with decreasing kidney function-73.5%, 69.6%, 65.4%, 59.5%, and 45.0% of the patients were prescribed a NOAC in estimated glomerular filtration rate ≥90, 60 to 90, 45 to 60, 30 to 45, 15 to 30 mL/min per 1.73 m groups, respectively. Stabilized inverse probability of treatment weighting was used to balance 4 treatment groups (apixaban, dabigatran, rivaroxaban, and warfarin) on 66 baseline characteristics. In comparison to warfarin, apixaban was associated with a lower risk of stroke (hazard ratio [HR], 0.57 [0.43-0.75]; <0.001), major bleeding (HR, 0.51 [0.44-0.61]; <0.001), and mortality (HR, 0.68 [0.56-0.83]; <0.001); dabigatran was associated with a similar risk of stroke but a lower risk of major bleeding (HR, 0.57 [0.43-0.75]; <0.001) and mortality (HR, 0.68 [0.48-0.98]; =0.04); rivaroxaban was associated with a lower risk of stroke (HR, 0.69 [0.51-0.94]; =0.02), major bleeding (HR, 0.84 [0.72-0.99]; =0.04), and mortality (HR, 0.73 [0.58-0.91]; =0.006). There was no significant interaction between treatment and estimated glomerular filtration rate categories for any outcome. When comparing one NOAC to another NOAC, there was no significant difference in mortality, but some differences existed for stroke or major bleeding. No relationship between treatments and falsification end points was found, suggesting no evidence for substantial residual confounding. Conclusions Relative to warfarin, NOACs are used less frequently as kidney function declines. However, NOACs appears to have similar or better comparative effectiveness and safety across the range of kidney function.



Circ Cardiovasc Qual Outcomes: 04 Oct 2020:CIRCOUTCOMES120006515; epub ahead of print
Yao X, Inselman JW, Ross JS, Izem R, ... Shah ND, Noseworthy PA
Circ Cardiovasc Qual Outcomes: 04 Oct 2020:CIRCOUTCOMES120006515; epub ahead of print | PMID: 33012172
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Abstract

Critical repolarization gradients determine the induction of reentry-based Torsade de Pointes arrhythmia in models of long QT syndrome.

Rivaud MR, Bayer JD, Cluitmans M, van der Waal J, ... Meijborg VMF, Coronel R
Background
Torsade de Pointes arrhythmia is a potentially lethal polymorphic ventricular tachyarrhythmia (pVT) in the setting of long QT syndrome. Arrhythmia susceptibility is influenced by risk factors modifying repolarization.
Objective
To characterize repolarization duration and heterogeneity in relation to pVT inducibility and maintenance.
Methods
Sotalol was infused regionally or globally in isolated Langendorff blood-perfused pig hearts (N=7) to create repolarization time (RT) heterogeneities. Programmed stimulation and epicardial activation and repolarization mapping were performed. The role of RT (heterogeneities) was studied in more detail using a computer model of the human heart.
Results
pVTs (n=11) were inducible at a critical combination of RT and RT heterogeneities. The pVT cycle lengths were similar in the short and long RT regions. Short-lasting pVTs were maintained by focal activity while longer-lasting pVTs by reentry wandering along the interface between the two regions. Local restitution curves from the long and short RT regions crossed. This was associated with T-wave inversion at coupling intervals at either side of the crossing-point. These experimental observations were confirmed by the computer simulations.
Conclusions
pVTs are inducible within a critical range of RT and RT heterogeneities and are maintained by reentry wandering along the repolarization gradient. Double potentials localize at the core of the reentrant circuit and reflect phase singularities. RT gradient and T-waves invert with short coupled premature beats in the long RT region as a result of the crossing of the restitution curves allowing reentry initiation.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 04 Oct 2020; epub ahead of print
Rivaud MR, Bayer JD, Cluitmans M, van der Waal J, ... Meijborg VMF, Coronel R
Heart Rhythm: 04 Oct 2020; epub ahead of print | PMID: 33031961
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Abstract

Blood-based 8-hydroxy-2\'-deoxyguanosine level: a potential diagnostic biomarker for Atrial Fibrillation.

Li J, Zhang D, Ramos KS, Baks L, ... de Groot NMS, Brundel BJJM
Background
Recent research findings revealed key role for oxidative DNA damage in the pathogenesis of atrial fibrillation (AF). Therefore, a circulating oxidative DNA damage marker 8-hydroxy-2\'-deoxyguanosine (8-OHdG) may represent a biomarker to stage AF and identify patients at risk for AF recurrence and POAF after treatment.
Objectives
To investigate whether serum levels of 8-OHdG correlate with the stage of AF, recurrence after AF treatment and onset of post-operative AF (POAF) after cardiac surgery.
Methods
In this prospective and observational study, 8-OHdG levels are detected by ELISA in human serum samples. Blood samples were collected from control patients without AF history, paroxysmal AF and persistent AF patients undergoing electrical cardioversion (ECV) or pulmonary vein isolation (PVI), and sinus rhythm (SR) patients undergoing cardiac surgery. AF recurrence was determined during 12 months follow-up. Univariate and multivariate analysis were used to identify changes in 8-OHdG levels between the groups.
Results
Compared to the control group, 8-OHdG levels gradually and significantly increased during progression of this arrhythmia. Also 8-OHdG levels in AF patients showing an AF recurrence after PVI treatment were significantly increased compared to patients without AF recurrence. Moreover, in SR patients undergoing cardiac surgery, 8-OHdG levels were significantly elevated in patients showing POAF compared to patients without POAF.
Conclusions
The level of 8-OHdG may represent a potential diagnostic biomarker for AF staging, as well as prediction of AF recurrence and POAF after treatment.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 04 Oct 2020; epub ahead of print
Li J, Zhang D, Ramos KS, Baks L, ... de Groot NMS, Brundel BJJM
Heart Rhythm: 04 Oct 2020; epub ahead of print | PMID: 33031960
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Abstract

Association between cardioplegia and postoperative atrial fibrillation in coronary surgery.

Mauro MD, Calafiore AM, Di Franco A, Nicolini F, ... Gaudino M, Lorusso R
Objective
The aim of this multicenter study was to evaluated whether cold or warm cardioplegia are associated with postoperative atrial fibrillation (POAF) and the prognostic role of the latter on early stroke and neurological mortality.
Method
This was a retrospective analysis of prospective collected data from 9 cardiac centers in Italy and the United States including patients undergoing surgery between 2010 and 2018. From the 9 institutional databases, 17,231 patients underwent isolated CABG on-pump, using either warm cardioplegia (n = 7730) or cold cardioplegia (n = 9501); among the latter group blood and crystalloid cardioplegia were used in 691 and 8810 patients, respectively. After matching, two pairs of 4162 patients (overall cohort 8324) were analyzed.
Results
In matched population, the rate of POAF was 18% (1472 cases), 15% (608) in warm group versus 21% (864) in cold group (p < 0.001). Multivariable analysis confirmed that cold cardioplegia was associated with higher rate of POAF, along with age, hypercholesterolemia, LVEF, reoperation, preoperative IABP, previous stroke, cardiopulmonary and cross-clamp. Moreover, cold cardioplegia as well as POAF increased the rate of postoperative stroke as well as early mortality and neurological mortality Propensity-weighted cohort included 11,830 (70%) patients out of 17,231. After adjustment, both cold blood and cold crystalloid cardioplegia negatively influenced POAF, stroke and neurological mortality.
Conclusions
Warm cardioplegia may reduce the rate of POAF in CABG patients with respect to cold cardioplegia, either blood or crystalloid. This has a prognostic impact on postoperative stroke and neurological mortality.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 03 Oct 2020; epub ahead of print
Mauro MD, Calafiore AM, Di Franco A, Nicolini F, ... Gaudino M, Lorusso R
Int J Cardiol: 03 Oct 2020; epub ahead of print | PMID: 33022288
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Impact:
Abstract

Differences Between Cardiac Implantable Electronic Device Envelopes Evaluated in an Animal Model.

Ip JE, Xu L, Lerman BB
Introduction
Cardiac implantable electronic device (CIED) pocket related problems such as infection, hematoma, and device erosion cause significant morbidity and the clinical consequences are substantial. Bio-absorbable materials have been developed to assist in the prevention of these complications but there has not been any direct comparison of these adjunctive devices to reduce these complications. We sought to directly compare the TYRX absorbable antibacterial and CanGaroo extracellular matrix (ECM) envelopes in an animal model susceptible to these specific CIED-related complications (i.e. skin erosion and infection).
Methods and results
Sixteen mice undergoing implantation with biopotential transmitters were divided into three groups (no envelope = 4, TYRX = 5, CanGaroo = 7) and monitored for device-related complications. Following 12 weeks of implantation, gross and histological analysis of the remaining capsules were performed. Three animals in the CanGaroo group (43%) had device erosion compared to none in the TYRX group. The remaining capsules excised at 12 weeks were qualitatively thicker following CanGaroo compared to TYRX and no envelope and histological evaluation demonstrated increased connective tissue with CanGaroo.
Conclusion
CanGaroo ECM envelopes did not reduce the incidence of device erosion and were associated with a qualitatively thicker capsules and connective tissue staining at 12 weeks compared to no envelope or TYRX. Further studies regarding use of these envelopes to prevent device erosion and their subsequent impact on capsule formation is warranted. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 02 Oct 2020; epub ahead of print
Ip JE, Xu L, Lerman BB
J Cardiovasc Electrophysiol: 02 Oct 2020; epub ahead of print | PMID: 33010088
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Impact:
Abstract

Envelopes on Cardiac Implantable Electronic Devices: Aiming at Zero.

Love CJ

In this issue of the Journal of Cardiac Electrophysiology, Ip and colleagues report on a study that evaluates a murine model of three different cohorts This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 02 Oct 2020; epub ahead of print
Love CJ
J Cardiovasc Electrophysiol: 02 Oct 2020; epub ahead of print | PMID: 33010082
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Abstract

Topographical anatomy of the right atrial appendage vestibule and its isthmuses.

Hołda J, Słodowska K, Tyrak K, Bolechała F, ... Hołda MK, Walocha JA
Introduction
The right atrial appendage (RAA) vestibule is an area located in the right atrium between the RAA orifice and the right atrioventricular valve annulus, and may be a target for invasive transcatheter procedures.
Methods and results
We examined 200 autopsied human hearts. Three isthmuses (an inferior, a middle and a superior isthmus) were detected. The average length of the vestibule was 67.4±10.1mm. Crevices and diverticula were observed within the vestibule in 15.3% of specimens. The isthmuses had varying heights: superior: 14.0±3.4mm, middle: 11.2±3.1mm and inferior: 10.1±2.7mm (p<0.001). Superior isthmus had the thickest atrial wall (at mid-level: 16.7±5.6mm), middle isthmus had the second thickest wall (13.5±4.2mm) and inferior isthmus had the thinnest wall (9.3±3.0mm) (p<0.001). This same pattern was observed when analyzing the thickness of adipose layer (superior isthmus had a thickness of 15.4±5.6mm, middle: 11.7±4.1mm and inferior: 7.1±3.1mm; p<0.001). The average myocardial thickness did not vary between isthmuses (superior isthmus: 1.3±0.5mm, middle isthmus: 1.8±0.8mm, inferior isthmus: 1.6±0.5mm; (p>0.05). Within each isthmus, there were variations in the thickness of the entire atrial wall and of the adipose layer. These were thickest near the valve annulus and thinnest near the RAA orifice (p<0.001). The thickness of the myocardial layer followed an inverse trend (p<0.001).
Conclusions
This study was the first to describe the detailed topographical anatomy of the right atrial appendage vestibule and that of its adjoining isthmuses. The substantial variability in the structure and dimensions of the RAA isthmuses may play a role in planning interventions within this anatomic region. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 02 Oct 2020; epub ahead of print
Hołda J, Słodowska K, Tyrak K, Bolechała F, ... Hołda MK, Walocha JA
J Cardiovasc Electrophysiol: 02 Oct 2020; epub ahead of print | PMID: 33010077
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Impact:
Abstract

Clinical, Electrocardiographic and Electrophysiological Characteristics, and Catheter Ablation Results of Left Upper Septal Premature Ventricular Complexes.

Kose S, Vurgun VK, Gokoglan Y, Balli M, Kabul HK
Background
To investigate the clinical, electrocardiographic, and electrophysiological characteristics and results of catheter ablation of left upper septal(LUS) premature ventricular complexes(PVCs) arising from the proximal left fascicular system.
Methods
Thirty-one patients who had undergone radiofrequency catheter ablation(RFCA) for idiopathic PVCs were enrolled in the study. All PVCs presented with narrow QRS complexes(<110ms) with precordial QRS morphology of incomplete right bundle branch block type or identical to the sinus rhythm QRS morphology. RFCA was applied to the LUS area where the earliest fascicular potential(FP) was recorded during mapping.
Results
The mean QRS duration during sinus rhythm(SR) and PVCs were 92.3±7.9 ms and 103.2±7.3 ms, respectively. The mean FP-V interval during PVC at the target site was 32.7±2.7 ms. The mean H-V interval during SR and PVCs were 45.1±2.7 and 21.3±3.6 ms, respectively. Left anterior hemiblock/left posterior hemiblock and left bundle branch block(LBBB) were observed in 16 (53.3%) and 4 (12.9%) patients after RFCA, respectively. The His to FP interval in SR and H-V interval during PVC were found as significant markers for predicting the post-ablation LBBB. RFCA was acutely successful in 29 of 31 patients(93.5%) in the first procedure. Two patients had recurrence of PVCs during follow-up and one of them underwent a second successful ablation. The overall success rate was 90.3%(28/31) in a mean follow-up duration of 24.3±15.4 months.
Conclusions
LUS-PVCs have distinctive electrocardiographic and electrophysiologic characteristics and can be managed successfully by focal RFCA with detailed FP mapping of the left upper septum with a mild risk of left bundle branch injury. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 02 Oct 2020; epub ahead of print
Kose S, Vurgun VK, Gokoglan Y, Balli M, Kabul HK
J Cardiovasc Electrophysiol: 02 Oct 2020; epub ahead of print | PMID: 33010075
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Impact:
Abstract

Levothyroxine dose and risk of atrial fibrillation: a nested case-control study.

Gong IY, Atzema CL, Lega IC, Austin PC, ... Rochon PA, Lipscombe LL
Background
Contemporary data on the effect of levothyroxine dose on the occurrence of atrial fibrillation (AF) are lacking, particularly in the older population. Our objective was to determine the effect of cumulative levothyroxine exposure on risk of AF and ischemic stroke in older adults.
Methods
We conducted a population-based observational study using healthcare databases from Ontario, Canada. We identified adults aged ≥66 years without a history of AF who filled at least one levothyroxine prescription between April 1 2007 and March 31 2016. Cases were defined as cohort members who had incident AF (emergency room visit or hospitalization) between the date of first levothyroxine prescription and December 31, 2017. Index date was date of AF. Cases were matched with up to five controls without AF on the same index date. Secondary outcome was ischemic stroke. Cumulative levothyroxine exposure was estimated based on total milligrams (mg) of levothyroxine dispensed in the year prior to index date. Using nested case-control approach, we compared outcomes between older adults who received high (≥0.125 mg/day), medium (0.075-0.125 mg/day), or low (0-0.075 mg/day) cumulative levothyroxine dose. We compared outcomes between current, recent past, and remote past levothyroxine use.
Results
Of 189,672 older adults treated with levothyroxine (mean age 82 years; 72% women), 30,560 (16.1%) had an episode of AF. Compared to low levothyroxine exposure, high and medium exposure was associated with significantly increased risk of AF after adjustment for covariates (adjusted odds ratio, aOR 1.29, 95% confidence interval, CI 1.23-1.35; aOR 1.08, 95% CI 1.04-1.11; respectively). No association was observed between levothyroxine exposure and ischemic stroke. Compared with current levothyroxine use, older adults with remote levothyroxine use had lower risks of AF (aOR 0.56, 95% CI 0.52-0.59) and ischemic stroke (aOR 0.61, 95% CI 0.56-0.67).
Conclusions
Among older persons treated with levothyroxine, levothyroxine at doses above 0.075 mg/day is associated with an increased risk of AF compared to lower exposure.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am Heart J: 02 Oct 2020; epub ahead of print
Gong IY, Atzema CL, Lega IC, Austin PC, ... Rochon PA, Lipscombe LL
Am Heart J: 02 Oct 2020; epub ahead of print | PMID: 33022231
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Impact:
Abstract

Anticoagulation for Stroke Prevention in Patients With Hypertrophic Cardiomyopathy and Atrial Fibrillation: A Review.

Nasser MF, Gandhi S, Siegel RJ, Rader F

Atrial fibrillation is the most common arrhythmia in patients with hypertrophic cardiomyopathy with a prevalence and incidence of 23% and 3.1% respectively. The risk of thromboembolism is high in patients with hypertrophic cardiomyopathy regardless of the CHADS2VASC score. This review includes five observational studies that focused on prevention of thromboembolism in patients with hypertrophic cardiomyopathy and atrial fibrillation. These papers evaluated and compared outcomes between patients on either warfarin or direct oral anticoagulants. Data showed that direct oral anticoagulants are effective and safe in this patient population and also may have a benefit over warfarin in thromboprophylaxis in patients with hypertrophic cardiomyopathy and atrial fibrillation. In conclusion, lifelong anticoagulation with warfarin is recommended to prevent thromboembolism in patients with atrial fibrillation and hypertrophic cardiomyopathy due to high risk of thromboembolism. The available observational data reviewed here suggests that direct oral anticoagulants may be safe and effective to be used in this patient population. However, adequately powered randomized controlled trials are needed to confirm their efficacy and safety.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 02 Oct 2020; epub ahead of print
Nasser MF, Gandhi S, Siegel RJ, Rader F
Heart Rhythm: 02 Oct 2020; epub ahead of print | PMID: 33022393
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Impact:
Abstract

Revascularisation therapies improve the outcomes of ischemic stroke patients with atrial fibrillation and heart failure.

Pana TA, Mohamed MO, Clark AB, Fahy E, Mamas MA, Myint PK
Background
Atrial fibrillation (AF) and heart failure (HF) carry a poor prognosis in acute ischaemic stroke (AIS). The impact of revascularisation therapies on outcomes in these patients is not fully understood.
Method
National Inpatient Sample (NIS) AIS admissions (January 2004-September 2015) were included (n = 4,597,428). Logistic regressions analysed the relationship between exposures (neither AF nor HF-reference, AF-only, HF-only, AF + HF) and outcomes (in-hospital mortality, length-of-stay >median and moderate-to-severe disability on discharge), stratifying by receipt of intravenous thrombolysis (IVT) or endovascular thrombectomy (ET).
Results
69.2% patients had neither AF nor HF, 16.5% had AF-only, 7.5% had HF-only and 6.7% had AF + HF. 5.04% and 0.72% patients underwent IVT and/or ET, respectively. AF-only and HF-only were each associated with 75-85% increase in the odds of in-hospital mortality. AF + HF was associated with greater than two-fold increase in mortality. Patients with AF-only, HF-only or AF + HF undergoing IVT had better or at least similar in-hospital outcomes compared to their counterparts not undergoing IVT, except for prolonged hospitalisation. Patients undergoing ET with AF-only, HF-only or AF + HF had better (in-hospital mortality, discharge disability, all-cause bleeding) or at least similar (length-of-stay) outcomes to their counterparts not undergoing ET. Compared to AIS patients without AF, AF patients had approximately 50% and more than two-fold increases in the likelihood of receiving IVT or ET, respectively.
Conclusions
We confirmed the combined and individual impact of co-existing AF or HF on important patient-related outcomes. Revascularisation therapies improve these outcomes significantly in patients with these comorbidities.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 02 Oct 2020; epub ahead of print
Pana TA, Mohamed MO, Clark AB, Fahy E, Mamas MA, Myint PK
Int J Cardiol: 02 Oct 2020; epub ahead of print | PMID: 33022289
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Impact:
Abstract

Time to change the times? Time of Recurrence of Ventricular Fibrillation during OHCA.

Spies DM, Kiekenap J, Rupp D, Betz S, Kill C, Sassen MC
Aim of the study
For out-of-hospital-cardiac-arrest (OHCA) due to ventricular fibrillation (VF) guidelines recommend early defibrillation followed by chest compressions for two minutes before analyzing shock success. If rhythm analysis reveals VF again, it is obscure whether VF persisted or reoccurred within the two-minutes-cycle of chest compressions after successful defibrillation. We investigated the time of VF-recurrence in OHCA.
Methods
We examined all cases of OHCA presenting with initial VF rhythm at arrival of ALS-ambulance (Marburg-Biedenkopf-County, 246.648 inhabitants) from January 2014-March 2018. Three independent investigators analyzed corpuls3® ECG-recordings. We included ECG-data from CPR-beginning until four minutes after the third shock. VF termination was defined as the absence of a VF-waveform within 5 s of shock delivery. VF recurrence was defined as the presence of a VF-waveform in the interval 5 s post shock delivery.
Results
We included 185 shocks in 82 patients. 74.1% (n = 137) of all shocks terminated VF, but VF recurred in 81% (n = 111). The median (IQR) time of VF-recurrences was 27 s (13.5 s/80.5 s) after shock. 51.4% (n = 57) of VF-recurrence occurred 5-30 s after shock, 13.5% (n = 15) VF-recurrence occurred 31-60 s after shock, 21.6% (n = 24) of VF-recurrence occurred 61-120 s after shock, 13.5% (n = 15) of VF-recurrence occurred 121-240 s after shock.
Conclusions
Although VF was terminated by defibrillation in 74.1%, VF recurred in 81% subsequent to the chest compression interval. Thus, VF reappears frequently and early. It is unclear to which extend chest compressions influence VF-relapse. Further studies need to re-evaluate the algorithm, timing of antiarrhythmic therapy or novel defibrillation strategies to minimize refibrillation during shockable OHCA.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 02 Oct 2020; epub ahead of print
Spies DM, Kiekenap J, Rupp D, Betz S, Kill C, Sassen MC
Resuscitation: 02 Oct 2020; epub ahead of print | PMID: 33022311
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Impact:
Abstract

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

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

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

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

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

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

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

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

Inflammation and adiposity: new frontiers in atrial fibrillation.

Vyas V, Hunter RJ, Longhi MP, Finlay MC

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

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

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

Effect of Temporary Interruption of Warfarin Due to an Intervention on Downstream Time in Therapeutic Range in Patients With Atrial Fibrillation (from ORBIT AF).

Madhavan M, Holmes DN, Piccini JP, Freeman JV, ... Gersh BJ,

The aim of this study was to quantify time in therapeutic range (TTR) before and after a temporary interruption of warfarin due to an intervention in the Outcomes Registry for Better Informed Treatment of atrial fibrillation (AF). AF patients on warfarin who had a temporary interruption followed by resumption were identified. A nonparametric method for estimating survival functions for interval censored data was used to examine the first therapeutic International Normalized Ratio (INR) after interruption. TTR was compared using Wilcoxon signed rank test. Cox proportional hazards model was used to investigate the association between TTR in the first 3 months after interruption and subsequent outcomes at 3 to 9 months. Of 9,749 AF patients, 71% were on warfarin. Over a median (IQR) follow-up of 2.6 (1.8 to 3.1) y, 33% of patients had a total of 3,022 temporary interruptions. The first therapeutic INR was recorded within 1 week in 35.0% (95% confidence interval 32.6% to 37.4%), 2 weeks in 54.6% (52.2% to 57.0%), 30 days in 70.0% (67.9% to 72.1%) and 90 days in 91.3% (90.0% to 92.5%) of patients. Compared with pre-interruption, TTR 3 months after interruption was significantly lower (61.1% [36.6% to 85.0%] vs 67.6% [50.0% to 81.3%], p <0.0001). A 10 unit increment in the TTR in the first 3 months after interruption was associated with a lower risk of major bleeding [Hazard ratio 0.91 (0.85 to 0.97), p = 0.005]. This association was noted in patients who received bridging anticoagulation, but not in those who did not. In conclusion, temporary interruption of warfarin is common, and nearly half of these patients had subtherapeutic INR after 2 weeks. Lower TTR in the first 3 months after interruption was associated with higher incidence of major bleeding in patients who received bridging anticoagulation.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2020; 132:66-71
Madhavan M, Holmes DN, Piccini JP, Freeman JV, ... Gersh BJ,
Am J Cardiol: 30 Sep 2020; 132:66-71 | PMID: 32826041
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Abstract

Effects of Atrial Fibrillation and Chronic Kidney Disease on Major Adverse Cardiovascular Events.

Ding WY, Lip GYH, Pastori D, Shantsila A

Atrial fibrillation (AF) is strongly linked to chronic kidney disease (CKD) and both of these conditions contribute to poor cardiovascular outcomes. We evaluated the impact of renal failure on major adverse cardiovascular events (MACE) in AF, and predictive value of the 2MACE score in this post-hoc analysis of the AMADEUS trial. The primary endpoint was MACE (composite of myocardial infarction, cardiac revascularisation and cardiovascular mortality). Secondary endpoints included the composite of stroke, major bleeding and non-cardiovascular mortality, and each of the specific outcomes separately. Of the 4,554 patients, 1,526 (33.5%) were females and the median age was 71 (IQR 64 to 77) years. There were 3,838 (84.3%) non-CKD and 716 (15.7%) CKD patients. The incidence of cardiovascular and non-cardiovascular mortality were 1.41% and 2.44% per 100 patient-years, respectively. There was no significant difference in crude study endpoints between the groups. Multivariable regression analysis found no association between CKD and MACE (HR 1.03 [95% CI, 0.45 to 2.34]). The c-index of the 2MACE score for MACE was 0.65 (95% CI, 0.59 to 0.71, p <0.001). In the presence of CKD, each additional point of the 2MACE score contributed to a greater risk of MACE (HR 3.17 [95% CI, 1.28 to 7.85] vs 1.48 [95% CI, 1.17 to 1.87] in the non-CKD group). In conclusion, the 2MACE score may be a useful tool for clinical risk stratification of high-risk AF patients with CKD and those at high MACE risk could be targeted for more intensive cardiovascular prevention strategies. The presence of CKD was not found to be independently associated with MACE in AF patients.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2020; 132:72-78
Ding WY, Lip GYH, Pastori D, Shantsila A
Am J Cardiol: 30 Sep 2020; 132:72-78 | PMID: 32773222
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Abstract

Pulmonary vein isolation with the cryoballoon in obese atrial fibrillation patients - Does weight have an impact on procedural parameters and clinical outcome?

Weinmann K, Bothner C, Rattka M, Aktolga D, ... Dahme T, Pott A
Introduction
Obesity is a known risk factor for the incidence and prevalence of atrial fibrillation (AF). Pulmonary vein isolation (PVI) is an established therapeutic option for AF patients, however clinical benefit of AF ablation remains controversial in overweight and obese patients. We investigated the impact of overweight and obesity in AF patients undergoing cryoballoon PVI on procedural characteristics and clinical outcome.
Methods
We included consecutive patients undergoing cryoballoon PVI at Ulm University Medical center. Normal weight was defined as a body mass index (BMI) of 18.5-24.9 kg/m, overweight as a BMI of 25.0-29.9 kg/m and obesity as a BMI of ≥30.0 kg/m.
Results
Evaluating 600 patients, mean age was 66.3±10.8 years and 43% patients were female. 41% of the patients were classified as overweight and 34% as obese. Regarding procedural characteristics, overweight and obese patients had longer fluoroscopy area dose product (p<0.001) and obese patients a higher fluoroscopy time (p<0.05). Analyses of ablation related procedural characteristics revealed no relevant differences regarding number and duration of ablation, time to isolation and nadir temperature. Importantly, recurrence of atrial arrhythmia was statistically not different comparing normal weight, overweight and obese patients.
Conclusion
Besides higher radiation exposure, cryoballoon PVI in overweight and obese patients is as safe and efficient as in normal weight patients. It is reasonable to proceed with cryoballoon PVI on overweight and obese patients as would be done in normal weight patients, since this might encourage overweight and obese patients to exercise.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 30 Sep 2020; 316:137-142
Weinmann K, Bothner C, Rattka M, Aktolga D, ... Dahme T, Pott A
Int J Cardiol: 30 Sep 2020; 316:137-142 | PMID: 32522675
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Abstract

High incidence of subclinical atrial fibrillation in patients with syncope monitored with implantable cardiac monitor.

Francisco-Pascual J, Olivella San Emeterio A, Rivas-Gándara N, Pérez-Rodón J, ... Cantalapiedra Romero J, Ferreira González I
Objective
The use of implantable cardiac monitors (ICM) is highly useful in syncope workup. Latest-generation devices can detect asymptomatic episodes of atrial fibrillation. The main objective of this study was to determine the incidence of subclinical atrial fibrillation (AF) detected in a patient population undergoing prolonged electrocardiographic monitoring with an ICM for the etiological workup of syncope.
Methods
Prospective observational study carried out in a tertiary hospital from April 2014 to October 2019. All consecutive adult patients monitored with a latest-generation ICM for syncope with no prior history of AF were included in the analysis.
Results
Of a total of 509 ICMs implanted during the study period, 208 patients fulfilled the inclusion criteria. 42 patients (20.2%) were found to have AF on ICM. The incidence of AF was 11.7 cases per 100 person-years (95% CI: 8.7-15.9 per 100 person-years). The median burden of AF was 0.2% (IQR 0-0.8%). Age, the presence of hypertension, chronic kidney disease, the size of the septum and left atrium on electrocardiogram and the presence of broad QRS on baseline electrocardiogram were predictors for the appearance of AF in the univariate analysis.
Conclusion
The incidental finding of atrial fibrillation in patients with syncope monitored with ICM is common. The burden of AF is low, and it is generally subclinical. These findings create added value for the use of ICM in the workup for syncope, although further studies are needed to determine the clinical benefit of documenting subclinical AF.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 30 Sep 2020; 316:110-116
Francisco-Pascual J, Olivella San Emeterio A, Rivas-Gándara N, Pérez-Rodón J, ... Cantalapiedra Romero J, Ferreira González I
Int J Cardiol: 30 Sep 2020; 316:110-116 | PMID: 32470530
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Impact:
Abstract

The value of extensive catheter linear ablation on persistent atrial fibrillation (the CLEAR-AF Study).

Yao Y, Hu F, Du Z, He J, ... Liang E, Wu L
Background
The ablation therapy for persistent atrial fibrillation (PerAF) is still a challenge due to the high recurrence rate. This study was aimed to investigate the value of extensive linear ablation with contact force sensing techniques for PerAF.
Methods
A total of 214 patients with PerAF were enrolled in five centers. The patients were randomly assigned to Group I (PVI + LA roof line+ LA anterior wall line) and Group II (PVI + LA roof line), mitral valve isthmus lines were added in both groups if the atrial fibrillation (AF) could not be terminated after all approaches above.
Results
Acute success rate of AF termination during the ablation procedure in Group I was significantly higher than Group II (P = 0.028). Two-years follow-up showed no significant difference in the sinus rhythm maintenance rate between the two groups (63.4% in group I vs. 57.2% in group II, P = 0.218). More patients in Group I recurred as organized atrial tachycardia (AT) and can be precisely mapped during repeat ablation procedures (15 vs. 2, P = 0.001). The Kaplan-Meier estimates of AF/AT-free survival after repeat ablation procedures were 76.2% in Group I and 47.1% in Group II (P = 0.039).
Conclusions
Extensive linear ablation with contact force monitoring did not improve the long-term outcomes for PerAF patients. Repeat ablation procedure showed a possible higher chance of sinus rhythm restoration during follow-up.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 30 Sep 2020; 316:125-129
Yao Y, Hu F, Du Z, He J, ... Liang E, Wu L
Int J Cardiol: 30 Sep 2020; 316:125-129 | PMID: 32461117
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Impact:
Abstract

A Superior-type Fast-slow Atrioventricular Nodal Reentrant Tachycardia Phenotype Mimicking the Slow-fast Type.

Kaneko Y, Nakajima T, Tamura S, Hasegawa H, ... Iizuka T, Kurabayashi M

- Superior-type fast-slow (sup-F/S-) atrioventricular nodal reentrant tachycardia (AVNRT) is a rare AVNRT variant using a superior (sup-) slow pathway (SP) as the retrograde limb. Its intracardiac appearance, characterized by a short atrio-His (AH) interval and the earliest site of atrial activation in the His-bundle (HB; EAA-HB), is an initial indicator for making a diagnosis.- Among 22 consecutive patients with sup-F/S-AVNRT, three (age, 68-81 years) patients had an apparent but not typical slow-fast (S/F) AVNRT characterized by a long AH interval and EAA-HB (tachy-long-AH).- The diagnosis of sup-F/S-AVNRT was based on the standard criteria in two patients and on the occurrence of Wenckebach-type AV block during tachycardia, which was attributable to a block at the lower common pathway (LCP) below the circuit of the AVNRT, detected owing to the LCP potentials, in one patient. As with the typical S/F-AVNRT, tachy-long-AH was induced after a jump in the AH interval. In contrast to typical S/F-AVNRT, fluctuation in the ventriculoatrial interval was observed during the tachy-long-AH. Ventricular overdrive pacing was unable to entrain or terminate the tachy-long-AH. Moreover, the tachy-long-AH reciprocally transited to/from sup-F/S-AVNRT spontaneously or was triggered by ventricular contractions while the atrial cycle length and EAA remained unchanged. Both tachycardias were cured by ablation at a single site in the right-side parahisian region of two patients and the non-coronary aortic cusp of one patient. Collectively, the essential circuit of both tachycardias was identical, and the tachy-long-AH was diagnosed as another phenotype of sup-F/S-AVNRT accompanied by sustained antegrade conduction via another bystander SP breaking through the HB owing to the repetitive antegrade block at the LCP, thus representing a long AH interval during the ongoing sup-F/S-AVNRT.- An unknown sup-F/S-AVNRT phenotype exists that apparently mimics the typical S/F-AVNRT and is also an unknown subtype of apparent S/F-AVNRT.



Circ Arrhythm Electrophysiol: 30 Sep 2020; epub ahead of print
Kaneko Y, Nakajima T, Tamura S, Hasegawa H, ... Iizuka T, Kurabayashi M
Circ Arrhythm Electrophysiol: 30 Sep 2020; epub ahead of print | PMID: 33000970
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Impact:
Abstract

Long-term Outcome of the Randomized Defibrillator After Primary Angioplasty (DAPA) Trial.

Haanschoten DM, Elvan A, Ramdat Misier AR, Delnoy PPHM, ... Verheugt FWA, Ottervanger JP

- The randomized Defibrillator After Primary Angioplasty (DAPA) trial aimed to evaluate the survival benefit of prophylactic implantable cardioverter defibrillator (ICD) implantation in early selected high-risk patients after primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI).- A randomized, multicenter, controlled trial compared ICD versus conventional medical therapy in high risk primary PCI patients, based on one of the following factors: left ventricular ejection fraction (LVEF) < 30% within 4 days after STEMI, primary ventricular fibrillation, Killip class ≥2 and/or TIMI flow < 3 after PCI. ICD was implanted 30-60 days after MI. Primary endpoint was all-cause mortality at 3 years follow-up. The trial prematurely ended after inclusion of 266 patients (38% of the calculated sample size). Additional survival assessment was performed in February 2019 for the primary endpoint.- A total of 266 patients, 78.2% males, with a mean age of 60.8 ± 11.3 years, were enrolled. 131 patients were randomized to the ICD arm and 135 patients to the control arm. All-cause mortality was significant lower in the ICD group (5% vs 13%, HR 0.37; 95% CI 0.15-0.95) after 3 years follow-up. Appropriate ICD therapy occurred in 9 patients at 3 years follow-up (5 within the first 8 months after implantation). After median long-term follow-up of 9 years (IQR, 3-11), total mortality (18% vs 38%, HR 0.58; 95% CI 0.37-0.91) and cardiac mortality (HR 0.52; 95% CI 0.28-0.99) was significant lower in the ICD group. Non-cardiac death was not significantly different between groups. LVEF increased ≥10% in 46.5% of the patients during follow up and the extent of improvement was similar in both study groups.- In this prematurely terminated and thus underpowered randomized trial, early prophylactic ICD implantation demonstrated lower total and cardiac mortality in high-risk STEMI patients treated with primary PCI.



Circ Arrhythm Electrophysiol: 30 Sep 2020; epub ahead of print
Haanschoten DM, Elvan A, Ramdat Misier AR, Delnoy PPHM, ... Verheugt FWA, Ottervanger JP
Circ Arrhythm Electrophysiol: 30 Sep 2020; epub ahead of print | PMID: 33003972
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Impact:
Abstract

Safely Administering Potential QTc Prolonging Therapy Across a Large Healthcare System in the COVID-19 Era.

Saleh M, Gabriels J, Chang D, Fishbein J, ... Mountantonakis SE, Epstein LM

- The SARs-CoV-2 coronavirus has resulted in a global pandemic. Hydroxychloroquine ± azithromycin have been widely used to treat COVID-19 despite a paucity of evidence regarding efficacy. The incidence of torsade de pointes (TdP) remains unknown. Widespread use of these medications forced overwhelmed healthcare systems to search for ways to effectively monitor these patients while simultaneously trying to minimize healthcare provider (HCP) exposure and use of personal protective equipment (PPE).- COVID-19 positive patients that received hydroxychloroquine ± azithromycin across 13 hospitals between March 1 and April 15 were included in this study. A comprehensive search of the electronic medical records was performed using a proprietary python script to identify any mention of QT prolongation, ventricular tachy-arrhythmias and cardiac arrest.- The primary outcome of TdP was observed in 1 (0.015%) out of 6,476 hospitalized COVID-19 patients receiving hydroxychloroquine ± azithromycin. Sixty-seven (1.03%) had hydroxychloroquine ± azithromycin held or discontinued due to an average QT prolongation of 60.5±40.5ms from a baseline QTc of 473.7±35.9ms to a peak QTc of 532.6±31.6ms. Of these patients, hydroxychloroquine ± azithromycin were discontinued in 58 patients (86.6%), while one or more doses of therapy were held in the remaining nine (13.4%). A simplified approach to monitoring for QT prolongation and arrythmia was implemented on April 5. There were no deaths related to the medications with the simplified monitoring approach and HCP exposure was reduced.- The risk of torsade de pointes is low in hospitalized COVID-19 patients receiving hydroxychloroquine ± azithromycin therapy.



Circ Arrhythm Electrophysiol: 30 Sep 2020; epub ahead of print
Saleh M, Gabriels J, Chang D, Fishbein J, ... Mountantonakis SE, Epstein LM
Circ Arrhythm Electrophysiol: 30 Sep 2020; epub ahead of print | PMID: 33003964
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Impact:
Abstract

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

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

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

Europace: 30 Sep 2020; 22:1509-1519
van Schie MS, Starreveld R, Roos-Serote MC, Taverne YJHJ, ... Bogers AJJC, de Groot NMS
Europace: 30 Sep 2020; 22:1509-1519 | PMID: 33033830
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Impact:
Abstract

Durability of posterior wall isolation after catheter ablation among patients with recurrent atrial fibrillation.

Markman TM, Hyman MC, Kumareswaran R, Arkles JS, ... Marchlinski FE, Nazarian S
Background
Electrical posterior wall isolation (PWI) is increasingly being used for the treatment of patients with atrial fibrillation (AF). Few data exist on the durability of PWI using current technology.
Objective
The purpose of this study was to characterize the frequency and location of posterior wall reconnection at the time of repeat catheter ablation for AF.
Methods
We performed a single-center retrospective cohort study of 50 patients undergoing repeat AF ablation after previous PWI. Durability of PWI was assessed at the time of repeat ablation based on posterior wall entrance and exit block. Sites of posterior wall reconnection were characterized based on review of recorded electrical signals and electroanatomic maps.
Results
At the time of repeat ablation, mean age was 67 ± 10 years, 31 of 50 patients had persistent AF, and mean CHADS-VASc score was 3.0 ± 1.8. Of the 50 patients, 30 had durable PWI at repeat ablation, 1.4 ± 1.6 years after the index procedure. Patients with posterior wall reconnection required repeat ablation earlier (0.9 ± 0.6 years vs1.8 ± 1.9 years from index PWI; P = .048) and were more likely to have atypical atrial flutter (55% vs 27%; P = .043). Among patients with posterior wall reconnection, the roof was the most common site of reconnection (14/20), and 12 patients had multiple regions of reconnection noted.
Conclusion
Posterior wall reconnection is noted in 40% of patients undergoing repeat ablation after an index PWI. The roof of the left atrium is the most common site of posterior wall reconnection.

Copyright © 2020 Heart Rhythm Society. All rights reserved.

Heart Rhythm: 29 Sep 2020; 17:1740-1744
Markman TM, Hyman MC, Kumareswaran R, Arkles JS, ... Marchlinski FE, Nazarian S
Heart Rhythm: 29 Sep 2020; 17:1740-1744 | PMID: 32389682
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Impact:
Abstract

Heart Failure and Atrial Fibrillation Modify the Associations of Nocturnal Blood Pressure Dipping Pattern With Mortality in Hemodialysis Patients.

Mayer CC, Schmaderer C, Loutradis C, Matschkal J, ... Wassertheurer S, Sarafidis PA

Heart failure (HF), hypertension, and abnormal nocturnal blood pressure dipping are highly prevalent in hemodialysis patients. Atrial fibrillation (AF) and HF might be important mediators for the association of abnormal dipping patterns with worse prognosis. Thus, the aim of this study is to investigate the association of dipping with mortality in hemodialysis patients and to assess the influence of AF and HF. In total, 525 hemodialysis patients underwent 24-hour ambulatory blood pressure monitoring. All-cause and cardiovascular mortality served as end points. Patients were categorized according to their systolic dipping pattern (dipper, nondipper, and reverse dipper). Cox regression analysis was performed to determine the association between dipping pattern and study end points with dipping as reference. Subgroup analysis was performed for patients with and without AF or HF. In total, 185 patients with AF or HF and 340 patients without AF or HF were included. During a median follow-up of 37.8 months, 177 patients died; 81 from cardiovascular causes. Nondipping and reverse dipping were significantly associated with all-cause mortality in the whole cohort (nondipper: hazard ratio, 1.95 [1.22-3.14]; =0.006; reverse dipper: hazard ratio, 2.31 [1.42-3.76]; <0.001) and in patients without AF or HF (nondipper: hazard ratio, 2.78 [1.16-6.66]; =0.02; reverse dipper: hazard ratio, 4.48 [1.87-10.71]; <0.001) but not in patients with AF or HF. For cardiovascular mortality, associations were again significant in patients without AF or HF and in the whole cohort. The observed associations remained significant after adjustment for possible confounders. This study provides well-powered evidence for the association between abnormal dipping patterns and mortality in hemodialysis patients and suggests that HF or AF modifies this association.



Hypertension: 29 Sep 2020; 76:1231-1239
Mayer CC, Schmaderer C, Loutradis C, Matschkal J, ... Wassertheurer S, Sarafidis PA
Hypertension: 29 Sep 2020; 76:1231-1239 | PMID: 32862707
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Abstract

Left Atrial Strain as a Predictor of New-Onset Atrial Fibrillation in Patients With Heart Failure.

Park JJ, Park JH, Hwang IC, Park JB, Cho GY, Marwick TH
Objectives
This study sought to identify whether left atrial strain can predict new-onset atrial fibrillation (NOAF) in patients with heart failure (HF) and sinus rhythm.
Background
Both HF and atrial fibrillation have common risk factors, and HF is a risk factor for the development of atrial fibrillation and vice versa.
Methods
Among 4,312 consecutive patients with acute HF from 3 tertiary hospitals, 2,461 patients with sinus rhythm and peak atrial longitudinal strain (PALS) were included in the study. Reduced PALS was defined as PALS ≤18%, and the primary endpoint was 5-year NOAF.
Results
During a 5-year follow-up, 397 (16.1%) patients developed NOAF. Patients with reduced PALS had higher NOAF than their counterparts (18.2% vs. 12.7%; p < 0.001). After adjustment for significant covariates, we identified 6 independent predictors of NOAF, including age >70 years (hazard ratio [HR]: 1.50; 95% confidence interval [CI]: 1.12 to 2.00), hypertension (HR: 1.45; 95% CI: 1.10 to 1.91), left atrial volume index ≥40 ml/m (HR: 2.03; 95% CI: 1.48 to 2.77), PALS <18% (HR: 1.60; 95% CI: 1.18 to 2.17), HF with preserved ejection fraction (HR: 1.47; 95% CI: 1.11 to 1.95), and no beta-blocker prescription at discharge (HR: 1.48; 95% CI: 1.14 to 1.92). A weighted score based on these variables was used to create a composite score, HAS-BAP (H = hypertension; A = age; S = PALS; B = no beta-blocker prescription at discharge; A = atrial volume index; P = HF with preserved ejection fraction [range 0 to 6] with a median of 3 [interquartile range: 2 to 4]). The probability of NOAF increased with HAS-BAP score.
Conclusions
In patients with HF and sinus rhythm, 16.1% developed NOAF, and PALS could be used to predict the risk for NOAF. The HAS-BAP score allows determination of the risk of NOAF. (Strain for Risk Assessment and Therapeutic Strategies in Patients With Acute Heart Failure [STRATS-AHF] Registry; NCT03513653).

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 29 Sep 2020; 13:2071-2081
Park JJ, Park JH, Hwang IC, Park JB, Cho GY, Marwick TH
JACC Cardiovasc Imaging: 29 Sep 2020; 13:2071-2081 | PMID: 32682715
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Abstract

Atrial fibrillation and the prothrombotic state: revisiting Virchow\'s triad in 2020.

Ding WY, Gupta D, Lip GYH

Atrial fibrillation (AF) is characterised by an increased risk of pathological thrombus formation due to a disruption of physiological haemostatic mechanisms that are better understood by reference to Virchow\'s triad of \'abnormal blood constituents\', \'vessel wall abnormalities\' and \'abnormal blood flow\'. First, there is increased activation of the coagulation cascade, platelet reactivity and impaired fibrinolysis as a result of AF per se, and these processes are amplified with pre-existing comorbidities. Several prothrombotic biomarkers including platelet factor 4, von Willebrand factor, fibrinogen, β-thromboglobulin and D-dimer have been implicated in this process. Second, structural changes such as atrial fibrosis and endothelial dysfunction are linked to the development of AF which promote further atrial remodelling, thereby providing a suitable platform for clot formation and subsequent embolisation. Third, these factors are compounded by the presence of reduced blood flow secondary to dilatation of cardiac chambers and loss of atrial systole which have been confirmed using various imaging techniques. Overall, an improved understanding of the various factors involved in thrombus formation will allow better clinical risk stratification and targeted therapies in AF.

© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 29 Sep 2020; 106:1463-1468
Ding WY, Gupta D, Lip GYH
Heart: 29 Sep 2020; 106:1463-1468 | PMID: 32675218
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Abstract

On-treatment HDL cholesterol predicts incident atrial fibrillation in hypertensive patients with left ventricular hypertrophy.

Okin PM, Hille DA, Wachtell K, Kjeldsen SE, Julius S, Devereux RB

: Hypertensive patients are at increased risk of atrial fibrillation (AF). Although low baseline high density lipoprotein (HDL) cholesterol has been associated with a higher risk of AF, this has not been verified in recent population-based studies. Whether changing levels of HDL over time are more strongly related to the risk of new AF in hypertensive patients has not been examined.: Incident AF was examined in relation to baseline and on-treatment HDL levels in 8267 hypertensive patients with no history of AF, in sinus rhythm on their baseline electrocardiogram, randomly assigned to losartan- or atenolol-based treatment. HDL levels at baseline and each year of testing were categorised into quartiles according to baseline HDL levels.: During 4.7 ± 1.10 years of follow-up, 645 patients (7.8%) developed new AF. In univariate Cox analyses, compared with the highest quartile of HDL levels (>1.78 mmol/l), patients with on-treatment HDL in the lowest quartile (≤ 1.21 mmol/l) had a 53% greater risk of new AF. Patients with on-treatment HDL in the second and third quartiles had intermediate increased risks of AF. Baseline HDL in the lowest quartile was not a significant predictor of new AF (hazard ratio (HR): 1.14, 95% confidence interval (CI): 0.90-1.43). In multivariable Cox analyses adjusting for multiple baseline and time-varying covariates, the lowest quartile of on-treatment HDL remained associated with a nearly 54% increased risk of new AF (HR: 1.54, 95% CI: 1.16-2.05) whereas a baseline HDL≤ ⩽1.21 mmol/l was not predictive of new AF (HR: 1.01, 95% CI: 0.78-1.31).: Lower on-treatment HDL is strongly associated with risk of new AF. These findings suggest that serial assessment of HDL can estimate AF risk better than baseline HDL in hypertensive patients with left ventricular hypertrophy. Future studies may investigate whether therapies that increase HDL can lower risk of developing AF.: http://clinicaltrials.gov/ct/show/NCT00338260?order=1.



Blood Pressure: 29 Sep 2020; 29:319-326
Okin PM, Hille DA, Wachtell K, Kjeldsen SE, Julius S, Devereux RB
Blood Pressure: 29 Sep 2020; 29:319-326 | PMID: 32586143
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Abstract

Diagnostic yield and long-term outcome of nonischemic sudden cardiac arrest survivors and their relatives: Results from a tertiary referral center.

Jacobsen EM, Hansen BL, Kjerrumgaard A, Tfelt-Hansen J, ... Bundgaard H, Winkel BG
Background
Cardiac arrest may be the first manifestation of most inherited cardiac diseases. International guidelines recommend screening of relatives of sudden cardiac arrest (SCA) survivors if an inherited cardiac disorder is suspected.
Objective
The purpose of this study was to assess the prevalence and spectrum of inherited cardiac diseases and the long-term outcome in a consecutive cohort of nonischemic SCA survivors (probands) and their relatives.
Methods
This retrospective study consecutively included probands and their relatives referred to our tertiary center for family screening between 2005 and 2018. All participants underwent a systematic workup and follow-up protocol. Data were retrieved from medical records.
Results
We included 155 probands (age 41.2 ± 15.5 years; 61% male) and 282 relatives (age 35.7 ± 18.8 years; 51% male). Mean follow-up was 7.1 years for probands and 4.4 years for relatives. We identified an inherited cardiac disease in 76 (49%) probands and 42 (15%) relatives. An implantable cardioverter-defibrillator was inserted in 147 (95%) probands and 9 (3%) relatives. During follow-up, 4 (3%) probands and 3 (1%) relatives died, and 37 probands and 2 relatives received appropriate shock therapy. All relatives received genetic counseling, and 18 (6%) relatives started pharmacologic treatment during follow-up.
Conclusion
Systematic workup of nonischemic SCA survivors and their relatives identified an inherited cardiac disease in 49% of referred probands and 15% of their relatives. The favorable long-term prognosis of diagnosed relatives probably not only reflects lower age but also the effects of early diagnosis, treatment, and follow-up. These findings support systematic workup of SCA survivors and their relatives.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Sep 2020; 17:1679-1686
Jacobsen EM, Hansen BL, Kjerrumgaard A, Tfelt-Hansen J, ... Bundgaard H, Winkel BG
Heart Rhythm: 29 Sep 2020; 17:1679-1686 | PMID: 32615163
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Abstract

Double (dual) sequential defibrillation for refractory ventricular fibrillation cardiac arrest: A systematic review.

Deakin CD, Morley P, Soar J, Drennan IR
Introduction
Cardiac arrests associated with shockable rhythms such as ventricular fibrillation or pulseless VT (VF/pVT) are associated with improved outcomes from cardiac arrest. The more defibrillation attempts required to terminate VF/pVT, the lower the survival. Double sequential defibrillation (DSD) has been used for refractory VF/pVT cardiac arrest despite limited evidence examining this practice. We performed a systematic review to summarize the evidence related to the use of DSD during cardiac arrest.
Methods
This review was performed according to PRISMA and registered on PROSPERO (ID: CRD42020152575). We searched Embase, Pubmed, and the Cochrane library from inception to 28 February 2020. We included adult patients with VF/pVT in any setting. We excluded case studies, case series with less than five patients, conference abstracts, simulation studies, and protocols for clinical trials. We predefined our outcomes of interest as neurological outcome, survival to hospital discharge, survival to hospital admission, return of spontaneous circulation (ROSC), and termination of VF/pVT. Risk of bias was examined using ROBINS-I or ROB-2 and certainty of studies were reported according to GRADE methodology.
Results
Overall, 314 studies were identified during the initial search. One hundred and thirty studies were screened during title and abstract stage and 10 studies underwent full manuscript screening, nine included in the final analysis. Included studies were cohort studies (n = 4), case series (n = 3), case-control study (n = 1) and a prospective pilot clinical trial (n-1). All studies were considered to have serious or critical risk of bias and no meta-analysis was performed. Overall, we did not find any differences in terms of neurological outcome, survival to hospital discharge, survival to hospital admission, ROSC, or termination of VF/pVT between DSD and a standard defibrillation strategy.
Conclusion
The use of double sequential defibrillation was not associated with improved outcomes from out-of-hospital cardiac arrest, however the current literature has a number of limitations to interpretation. Further high-quality evidence is needed to answer this important question.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 29 Sep 2020; 155:24-31
Deakin CD, Morley P, Soar J, Drennan IR
Resuscitation: 29 Sep 2020; 155:24-31 | PMID: 32561473
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Abstract

Sudden cardiac arrest with shockable rhythm in patients with heart failure.

Woolcott OO, Reinier K, Uy-Evanado A, Nichols GA, ... Jui J, Chugh SS
Background
Patients with shockable sudden cardiac arrest (SCA; ventricular fibrillation/tachycardia) have significantly better resuscitation outcomes than do those with nonshockable rhythm (pulseless electrical activity/asystole). Heart failure (HF) increases the risk of SCA, but presenting rhythms have not been previously evaluated.
Objective
We hypothesized that based on unique characteristics, HFpEF (HF with preserved ejection fraction; left ventricular ejection fraction [LVEF] ≥50%), bHFpEF (HF with borderline preserved ejection fraction; LVEF >40% and <50%), and HFrEF (HF with reduced ejection fraction; LVEF ≤40%) manifest differences in presenting rhythm during SCA.
Methods
Consecutive cases of SCA with HF (age ≥18 years) were ascertained in the Oregon Sudden Unexpected Death Study (2002-2019). LVEF was obtained from echocardiograms performed before and unrelated to the SCA event. Presenting rhythms were identified from first responder reports. Logistic regression was used to evaluate the independent association of presenting rhythm with HF subtype.
Results
Of 648 subjects with HF and SCA (median age 72 years; interquartile range 62-81 years), 274 had HFrEF (23.4% female), 92 had bHFpEF (35.9% female), and 282 had HFpEF (42.5% female). The rates of shockable rhythms were 44.5% (n = 122), 48.9% (n = 45), and 27.0% (n = 76) for HFrEF, bHFpEF, and HFpEF, respectively (P < .001). Compared with HFpEF, the adjusted odds ratios for shockable rhythm were 1.86 (95% confidence interval 1.27-2.74; P = .002) in HFrEF and 2.26 (95% CI 1.35-3.77; P = .002) in bHFpEF. The rates of survival to hospital discharge were 10.6% (n = 29) in HFrEF, 22.8% (n = 21) in bHFpEF, and 9.9% (n = 28) in HFpEF (P = .003).
Conclusion
The rates of shockable rhythm during SCA depend on the HF clinical subtype. Patients with bHFpEF had the highest likelihood of shockable rhythm, correlating with the highest rates of survival.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Sep 2020; 17:1672-1678
Woolcott OO, Reinier K, Uy-Evanado A, Nichols GA, ... Jui J, Chugh SS
Heart Rhythm: 29 Sep 2020; 17:1672-1678 | PMID: 32504821
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Abstract

Outer loop and isthmus in ventricular tachycardia circuits: Characteristics and implications.

Frontera A, Pagani S, Limite LR, Hadjis A, ... Quarteroni A, Della Bella P
Background
The isthmus of ventricular tachycardia (VT) circuits has been extensively characterized. Few data exist regarding the contribution of the outer loop (OL) to the VT circuit.
Objective
The purpose of this study was to characterize the electrophysiological properties of the OL.
Methods
Complete substrate activation mapping during sinus rhythm (SR) and full activation mapping of the VT circuit with high-density mapping were performed. Maps were analyzed mathematically to reconstruct conduction velocities (CVs) within the circuit. CV >100 cm/s was defined as normal and <50 cm/s as slow. Electrograms along the entire circuit were analyzed for fractionation, duration, and amplitude.
Results
Six postmyocardial infarction patients were enrolled. The VT circuit was a figure-of-eight reentrant circuit in 4 patients and a single-loop circuit in 2 patients. The OL exhibited a mean of 1.9 ± 0.9 and 1.6 ± 0.5 corridors of slow conduction (SC) during VT and SR, respectively. SC in the OL were longer and faster than SC in the isthmus during SR. At the OL, SC sites showed local abnormal ventricular activity in 92%, and a bipolar voltage <0.5 mV was identified in 80.7%. Of the double-loop circuits, only 1 patient had fixed lines of block as isthmus boundaries, whereas in 3 patients the circuits were at least partially functional.
Conclusion
In ischemic reentrant VT circuits, the OL contributes significantly to reentry with multiple corridors of SC. These corridors can result from structural or functional phenomena. Isthmus boundaries may correspond to functional or fixed lines of block.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Sep 2020; 17:1719-1728
Frontera A, Pagani S, Limite LR, Hadjis A, ... Quarteroni A, Della Bella P
Heart Rhythm: 29 Sep 2020; 17:1719-1728 | PMID: 32497763
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Abstract

Loss of ventricular preexcitation during noninvasive testing does not exclude high-risk accessory pathways: A multicenter study of WPW in children.

Escudero CA, Ceresnak SR, Collins KK, Pass RH, ... Etheridge SP, Janson CM
Background
Abrupt loss of ventricular preexcitation on noninvasive evaluation, or nonpersistent preexcitation, in Wolff-Parkinson-White syndrome (WPW) is thought to indicate a low risk of life-threatening events.
Objective
The purpose of this study was to compare accessory pathway (AP) characteristics and occurrences of sudden cardiac arrest (SCA) and rapidly conducted preexcited atrial fibrillation (RC-AF) in patients with nonpersistent and persistent preexcitation.
Methods
Patients 21 years or younger with WPW and invasive electrophysiology study (EPS) data, SCA, or RC-AF were identified from multicenter databases. Nonpersistent preexcitation was defined as absence/sudden loss of preexcitation on electrocardiogram, Holter monitoring, or exercise stress test. RC-AF was defined as clinical preexcited atrial fibrillation with shortest preexcited R-R interval (SPERRI) ≤ 250 ms. AP effective refractory period (APERP), SPERRI at EPS , and shortest preexcited paced cycle length (SPPCL) were collected. High-risk APs were defined as APERP, SPERRI, or SPPCL ≤ 250 ms.
Results
Of 1589 patients, 244 (15%) had nonpersistent preexcitation and 1345 (85%) had persistent preexcitation. There were no differences in sex (58% vs 60% male; P=.49) or age (13.3±3.6 years vs 13.1±3.9 years; P=.43) between groups. Although APERP (344±76 ms vs 312±61 ms; P<.001) and SPPCL (394±123 ms vs 317±82 ms; P<.001) were longer in nonpersistent vs persistent preexcitation, there was no difference in SPERRI at EPS (331±71 ms vs 316±73 ms; P=.15). Nonpersistent preexcitation was associated with fewer high-risk APs (13% vs 23%; P<.001) than persistent preexcitation. Of 61 patients with SCA or RC-AF, 6 (10%) had nonpersistent preexcitation (3 SCA, 3 RC-AF).
Conclusion
Nonpersistent preexcitation was associated with fewer high-risk APs, though it did not exclude the risk of SCA or RC-AF in children with WPW.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Sep 2020; 17:1729-1737
Escudero CA, Ceresnak SR, Collins KK, Pass RH, ... Etheridge SP, Janson CM
Heart Rhythm: 29 Sep 2020; 17:1729-1737 | PMID: 32497761
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Abstract

Risks and outcomes of gastrointestinal malignancies in anticoagulated atrial fibrillation patients experiencing gastrointestinal bleeding: A nationwide cohort study.

Chang TY, Chan YH, Chiang CE, Lin YJ, ... Chen SA, Chao TF
Background
Oral anticoagulants (OACs) may serve as a \"screening test\" for gastrointestinal (GI) tract malignancies through the clinical presentation of bleeding.
Objective
The purpose of this study was to investigate the 1-year incidence and predictors of GI cancer after GI bleeding among atrial fibrillation (AF) patients treated with warfarin or non-vitamin K antagonist oral anticoagulants (NOACs). The risks of mortality after GI cancers between patients receiving warfarin and those receiving NOACs were compared.
Methods
A total of 10,845 anticoagulated AF patients hospitalized due to GI bleeding without a previous history of GI cancer were identified from the Taiwan National Health Insurance Research Database. Patients were followed-up for incident GI cancers for up to 1 year.
Results
Within 1 year after GI bleeding, 290 patients (2.67%) were diagnosed with GI tract cancer. More patients treated with NOACs were diagnosed with GI cancer than those treated with warfarin (3.87% vs 2.44%; P <.001; odds ratio [OR] 1.606; P <.001). Age (OR 1.025 per 1-year increment) and male sex (OR 1.356) were associated with the diagnosis of GI cancer. Among patients diagnosed with GI cancer, 45.2% died within 1 year. The risk of mortality was lower in patients treated with NOACs than in those treated with warfarin (23.5% vs 51.8%; adjusted hazard ratio 0.441; P <.001).
Conclusion
Incident GI cancers were diagnosed in 1 of 37 AF patients at 1 year after OAC-related GI bleeding and were more common among patients treated with NOACs (1/26) compared to warfarin (1/41). Detailed examinations for occult GI cancers are necessary, especially among elderly males.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Sep 2020; 17:1745-1751
Chang TY, Chan YH, Chiang CE, Lin YJ, ... Chen SA, Chao TF
Heart Rhythm: 29 Sep 2020; 17:1745-1751 | PMID: 32470625
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Abstract

Purkinje system hyperexcitability and ventricular arrhythmia risk in type 3 long QT syndrome.

Barake W, Giudicessi JR, Asirvatham SJ, Ackerman MJ
Background
Gain-of-function variants in the SCN5A-encoded Na1.5 sodium channel cause type 3 long QT syndrome (LQT3) and multifocal ectopic Purkinje-related premature contractions. Although the Purkinje system is uniquely sensitive to the action potential-prolonging effects of LQT3-causative variants, the existence of additional Purkinje phenotype(s) in LQT3 is unknown.
Objective
The purpose of this study was to determine the prevalence and clinical implications of frequent fascicular/Purkinje-related premature ventricular contractions (PVCs) and short-coupled ventricular arrhythmias (VAs), suggestive of Purkinje system hyperexcitability (PSH), in a single-center LQT3 cohort.
Methods
A retrospective analysis of 177 SCN5A-positive patients was performed to identify individuals with a LQT3 phenotype. Available electrocardiographic, electrophysiology study, device, and genetic data from 91 individuals with LQT3 were reviewed for evidence of presumed fascicular PVCs and short-coupled VAs. The relationship between PSH and ventricular fibrillation events was assessed by Kaplan-Meier and Cox regression analyses.
Results
Overall, 30 of 91 patients with LQT3 (33%) exhibited evidence of presumed PSH (fascicular PVCs 30 of 30 [100%]; short-coupled VAs 17 of 30 [56%]). Kaplan-Meier and Cox regression analyses demonstrated an increased risk of ventricular fibrillation events in individuals with LQT3 and PSH (log-rank, P < .03; hazard ratio 3.95; 95% confidence interval 1.15-15.7; P = .03). Interestingly, variants in the voltage-sensing domain regions of Na1.5 were more frequently observed in patients with LQT3 and PSH than those without (19 of 30 [63%] vs 9 of 61 [15%]; P < .0001).
Conclusion
This study demonstrates that a discernible Purkinje phenotype is present in one-third of LQT3 cases and increases the risk of potentially lethal VAs. Further study is needed to determine whether a distinct cellular electrophysiology phenotype underlies this phenomenon.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 29 Sep 2020; 17:1768-1776
Barake W, Giudicessi JR, Asirvatham SJ, Ackerman MJ
Heart Rhythm: 29 Sep 2020; 17:1768-1776 | PMID: 32454217
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Abstract

QRS morphology in lead V for the rapid localization of idiopathic ventricular arrhythmias originating from the left ventricular papillary muscles: A novel electrocardiographic criterion.

Briceño DF, Santangeli P, Frankel DS, Liang JJ, ... Marchlinski FE, Schaller RD
Background
Twelve-lead electrocardiogram (ECG) criteria have been developed to identify idiopathic ventricular arrhythmias (VAs) from the left ventricular (LV) papillary muscles (PAPs), but accurate localization remains a challenge.
Objective
The purpose of this study was to develop ECG criteria for accurate localization of LV PAP VAs using lead V exclusively.
Methods
Consecutive patients undergoing mapping and ablation of VAs from the LV PAPs guided by intracardiac echocardiography from 2007 to 2018 were reviewed (study group). The QRS morphology in lead V was compared to patients with VAs with a \"right bundle branch block\" morphology from other LV locations (reference group). Patients with structural heart disease were excluded.
Results
One hundred eleven patients with LV PAP VAs (mean age 54 ± 16 years; 65% men) were identified, including 64 (55%) from the posteromedial PAP and 47 (42%) from the anterolateral PAP. The reference group included patients with VAs from the following LV locations: fascicles (n = 21), outflow tract (n = 36), ostium (n = 37), inferobasal segment (n = 12), and apex (5). PAP VAs showed 3 distinct QRS morphologies in lead V 93% of the time: Rr (53%), R with a slurred downslope (29%), and RR (11%). Sensitivity, specificity, positive predictive value, and negative predictive value for the 3 morphologies combined are 93%, 98%, 98%, and 93%, respectively. The intrinsicoid deflection of PAP VAs in lead V was shorter than that of the reference group (63 ± 13 ms vs 79 ± 24 ms; P < .001). An intrinsicoid deflection time of <74 ms best differentiated the 2 groups (sensitivity 79%; specificity 87%).
Conclusion
VAs originating from the LV PAPs manifest unique QRS morphologies in lead V, which can aid in rapid and accurate localization.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Sep 2020; 17:1711-1718
Briceño DF, Santangeli P, Frankel DS, Liang JJ, ... Marchlinski FE, Schaller RD
Heart Rhythm: 29 Sep 2020; 17:1711-1718 | PMID: 32454219
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Impact:
Abstract

Ventricular tachycardia in cardiolaminopathy: Characteristics and considerations for device programming.

Sidhu K, Han L, Picard KCI, Tedrow UB, Lakdawala NK
Background
Mutations in LMNA cause an arrhythmogenic cardiomyopathy (cardiolaminopathy) with high risk of ventricular tachycardia (VT). The natural history of VT among patients with cardiolaminopathy is incompletely understood.
Objective
The purpose of this study was to determine the longitudinal burden and progression of VT, including change in tachycardia cycle length (TCL), response to antitachycardia pacing (ATP), and prognostic significance of high-burden VT (>5 episodes of VT at any device interrogation) in cardiolaminopathy patients.
Methods
Patients with cardiolaminopathy and an implantable cardioverter-defibrillator (ICD) were identified from a single-center database. Serial device interrogations and medical records were used to collect data on VT burden, TCL, and response to ATP.
Results
Cardiolaminopathy patients with primary (n = 27) or secondary prevention (n = 16) ICDs were followed for 2 years (interquartile range [IQR] 1-5). VT burden was substantially higher in patients receiving secondary prevention ICDs (28 ± 40.9 vs 3.6 ± 7.3 episodes per 100 patient-years; P <.001). ATP was highly effective (94%) at terminating VT except for short TCL (<250 ms), for which ATP failed in 60%. Among patients with recurrent VT, TCL increased by 112 ± 93.6 ms during follow-up. Inappropriate shocks were rare (0.4% of all therapies). Median time to transplantation, ventricular assist device, or death was 18 months (IQR 0.7-27.1) in patients with high-burden VT.
Conclusion
In patients with cardiolaminopathy, VT is recurrent and highly responsive to ATP, which supports the use of transvenous ICDs iteratively programmed to manage VT of various TCLs. Onset of high-burden VT indicates poor prognosis and should warrant referral to a heart failure specialist.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Sep 2020; 17:1704-1710
Sidhu K, Han L, Picard KCI, Tedrow UB, Lakdawala NK
Heart Rhythm: 29 Sep 2020; 17:1704-1710 | PMID: 32454220
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Impact:
Abstract

Use of virtual visits for the care of the arrhythmia patient.

Hu PT, Hilow H, Patel D, Eppich M, ... Wazni O, Tarakji KG
Background
Virtual visits (VVs) are a modality for delivering health care services remotely through videoconferencing tools. Data about patient and physician experience in using VVs are limited.
Objective
The purpose of this study was to assess patient and physician experience with the use of VVs in cardiac electrophysiology.
Methods
We performed a prospective survey of cardiac electrophysiology patients and physicians who participated in an outpatient VV from December 2018 to July 2019.
Results
One-hundred consecutive VVs were included. Sixty-four patients elected to complete a survey. Patients rated their experience as either excellent/very good in scheduling a VV (87%), seeing their physician of choice (100%), transmitting arrhythmia data (88%), rating their physician\'s ability to communicate (98%), asking all questions (98%), rating the level of care received (98%), paying for the cost of a VV (67%), and rating their overall level of satisfaction (98%). Thirty-eight of 64 patients (59.4%) preferred a VV for their next visit, 12 of 64 (18.8%) preferred an in-office visit, 13 of 64 (20.3%) responded that their decision for a virtual or office visit depended on indication, and 1 of 64 (1.6%) had no preference. A total of 14 cardiac electrophysiologists participated in 100 VVs. Nine visits were not included due to technical difficulty. Physician responses to survey questions were rated as excellent/very good in the ability to communicate (92%), accessing monitoring data (95%), and overall level of satisfaction (98%).
Conclusion
In our small study population, most patients and physicians prefer VVs. Convenience, cost, and reason for follow-up were important determinants that affected both patient and physician preference.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Sep 2020; 17:1779-1783
Hu PT, Hilow H, Patel D, Eppich M, ... Wazni O, Tarakji KG
Heart Rhythm: 29 Sep 2020; 17:1779-1783 | PMID: 32438016
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Abstract

Ten-year outcomes of transcaval cardiac puncture for catheter ablation after extracardiac Fontan surgery.

Moore JP, Gallotti RG, Tran E, Perens GS, Shannon KM
Background
Although they are at lower risk, patients with previous extracardiac conduit (EC) Fontan still may require catheter ablation for supraventricular arrhythmia.
Objective
The purpose of this study was to determine the optimal approach to pulmonary venous atrium (PVA) access after EC Fontan operation.
Methods
All electrophysiological procedures requiring PVA over a 10-year period at the UCLA Medical Center were reviewed. PVA was grouped by transcaval cardiac puncture (TCP) or direct conduit puncture. Procedural characteristics and outcomes were compared.
Results
Between June 2009 and November 2019, 23 electrophysiological procedures requiring PVA access were performed in 17 EC Fontan patients (53% male; median age 25 years; interquartile range 11-34). Cavoatrial overlap was identified in 14 patients by preprocedural imaging (10 cardiac computed tomography, 4 cardiac magnetic resonance). PVA access was obtained via TCP in 11, direct conduit puncture in 6, pre-existing fenestration in 5, and pulmonary artery puncture in 1. Time to PVA was significantly shorter for TCP vs direct conduit puncture (0.2 vs 1.1 hours, respectively; P = .03). The only predictor of successful TCP was the length of cavoatrial overlap by preprocedural imaging (14 vs 3 mm; P = .02). No procedural complications occurred. No change in oxygen saturation was noted, and no evidence of residual shunting was detected by follow-up echocardiography.
Conclusion
TCP is feasible in most patients after EC Fontan surgery and can be predicted by preprocedural advanced imaging. TCP is associated with shorter time to PVA and was uncomplicated in this single-center study. Preoperative assessment of cavoatrial overlap should be considered before catheter ablation for EC Fontan.

Published by Elsevier Inc.

Heart Rhythm: 29 Sep 2020; 17:1752-1758
Moore JP, Gallotti RG, Tran E, Perens GS, Shannon KM
Heart Rhythm: 29 Sep 2020; 17:1752-1758 | PMID: 32438019
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Abstract

Long-term outcomes of ventricular tachycardia substrate ablation incorporating hidden slow conduction analysis.

Acosta J, Soto-Iglesias D, Jáuregui B, Armenta JF, ... Mont L, Berruezo A
Background
Ventricular tachycardia substrate ablation (VTSA) incorporating hidden slow conduction (HSC) analysis allows further arrhythmic substrate identification.
Objective
The purpose of this study was to analyze whether the elimination of HSC electrograms (HSC-EGMs) during VTSA results in better short- and long-term outcomes.
Methods
Consecutive patients (N = 70; 63% ischemic; mean age 64 ± 14.6 years) undergoing VTSA were prospectively included. Bipolar EGMs with >3 deflections and duration <133 ms were considered as potential HSC-EGMs. Whenever a potential HSC-EGM was identified, double or triple ventricular extrastimuli were delivered. If a local potential showed up as a delayed component, it was annotated as HSC-EGM. Ablation was delivered at conducting channel entrances and HSC-EGMs. Radiofrequency time, ventricular tachycardia (VT) inducibility after VTSA, and VT/ventricular fibrillation recurrence at 24 months after the procedure were compared with data from a historical control group.
Results
A total of 5076 EGMs were analyzed; 1029 (20.2%) qualified as potential HSC-EGMs, and 475 of them were tagged as HSC-EGMs. Scars in patients with HSC-EGMs (n = 43 [61.4%]) were smaller (32.2 [17-58] cm vs 85 [41-92.4] cm; P = .006) and more heterogeneous (core/scar area ratio 0.15 [0.05-0.44] vs 0.44 [0.33-0.57]; P = .017); 32.4% of HSC-EGMs were located in normal voltage tissue. Patients undergoing VTSA incorporating HSC analysis required less radiofrequency time (15.6 [8-23.1] vs 23.9 [14.9-30.8]; P < .001) and had a lower rate of VT inducibility after VTSA (28.6% vs 52.9%; P = .003) than did the historical controls. Patients undergoing VTSA incorporating HSC analysis showed a higher 2-year VT/ventricular fibrillation-free survival (75.7% vs 58.8%; log-rank, P = .046) after VTSA.
Conclusion
VTSA incorporating HSC analysis allowed further arrhythmic substrate identification (especially in the border zone and normal voltage areas) and was associated with increased VTSA efficiency and better short- and long-term outcomes.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Sep 2020; 17:1696-1703
Acosta J, Soto-Iglesias D, Jáuregui B, Armenta JF, ... Mont L, Berruezo A
Heart Rhythm: 29 Sep 2020; 17:1696-1703 | PMID: 32417258
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Abstract

Automated electrocardiographic quantification of myocardial scar in patients undergoing primary prevention implantable cardioverter-defibrillator implantation: Association with mortality and subsequent appropriate and inappropriate therapies.

Reichlin T, Asatryan B, Vos MA, Willems R, ... Sticherling C,
Background
Myocardial scarring from infarction or nonischemic fibrosis forms an arrhythmogenic substrate. The Selvester QRS score has been developed to estimate myocardial scar from the 12-lead electrocardiogram.
Objective
We aimed to assess the value of an automated version of the Selvester QRS score for the prediction of implantable cardioverter-defibrillator (ICD) therapy and death in patients undergoing primary prevention ICD implantation.
Methods
Unselected patients undergoing primary prevention ICD implantation were included in this retrospective, observational, multicenter study. The QRS score was calculated automatically from a digital standard preimplantation 12-lead electrocardiogram and was correlated to the occurrence of death and appropriate and inappropriate shocks during follow-up. Analyses were performed in groups defined by QRS duration < 130 ms vs ≥ 130 ms.
Results
Overall, 1047 patients (872 [83%] men; median age 64 years IQR [55-71]) with ischemic (648, 62%) or nonischemic (399, 38%) cardiomyopathy were included. The median QRS duration was 123 ms (interquartile range [IQR] 111-157 ms), and the median QRS score was 5 (IQR 2-8). The QRS duration was <130 ms in 59% and ≥130 ms in 41%. During a median follow-up of 45 months (IQR 24-72 months), a QRS score of ≥5 was independently associated with a significantly higher risk of mortality (hazard ratio [HR] 1.67; 95% confidence interval [CI] 1.05-2.66; P = .031) and appropriate (HR 1.83; 95% CI 1.07-3.14; P = .028) and inappropriate (HR 2.32; 95% CI 1.04-5.17; P = .039) shocks in patients with QRS duration ≥ 130 ms. No association of the QRS score and outcome was observed in patients with QRS duration < 130 ms (P > .05).
Conclusion
The automatically calculated Selvester QRS score, an indicator of myocardial scar burden, predicts mortality and appropriate and inappropriate shocks in patients undergoing primary prevention ICD implantation with a prolonged QRS duration.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Sep 2020; 17:1664-1671
Reichlin T, Asatryan B, Vos MA, Willems R, ... Sticherling C,
Heart Rhythm: 29 Sep 2020; 17:1664-1671 | PMID: 32428669
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Abstract

A novel 9-partition method using fluoroscopic images for guiding left bundle branch pacing.

Jiang H, Hou X, Qian Z, Wang Y, ... Li K, Zou J
Background
Left bundle branch (LBB) pacing is a novel pacing modality, but there is no standard fluoroscopic methodology.
Objectives
This study aimed to analyze the characteristics of His bundle (HB) and LBB pacing lead locations and establish a method to guide LBB pacing using fluoroscopic images.
Methods
Seventy patients who underwent HB or LBB pacing were enrolled. The fluoroscopic image was recorded, and ventricular contraction ring in the right anterior oblique 30° projection was determined. The region between the apex and the ventricular contraction ring was divided into 9 partitions. All patients underwent postoperative computed tomography to confirm components of the ventricular contraction ring and to measure the distance from the lead tip to the junction of the noncoronary aortic cusp and right coronary cusp.
Results
HB and LBB pacing leads were successfully implanted in 11 and 35 patients, respectively. All HB pacing leads were distributed in the second partition, and 94.3% (33/35) of LBB pacing leads were in the junctional area of second and fifth partitions. The computed tomography image confirmed that the ventricular contraction ring was composed of cardiac valves. The distance from the lead tip to the junction of the noncoronary cusp and right coronary cusp of LBB and HB pacing leads was 3.8 ± 0.6 and 1.9 ± 0.2 cm, respectively. Under the guidance of the 9-partition method, the success rate of LBB pacing in 30 prospective patients increased from 58.3% (35/60) to 83.3% (25/30) (P = .03). The fluoroscopy time and the number of screwing sites also significantly decreased.
Conclusion
The distributions of HB and LBB pacing leads exhibited unique imaging characteristics. A new 9-partition method is useful to guide successful LBB pacing.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Sep 2020; 17:1759-1767
Jiang H, Hou X, Qian Z, Wang Y, ... Li K, Zou J
Heart Rhythm: 29 Sep 2020; 17:1759-1767 | PMID: 32417259
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This program is still in alpha version.