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Background Cryoballoon pulmonary vein isolation (PVI) is a common therapy for atrial fibrillation (AF). While moderately increased sinus rhythm heart rate (HR) after PVI has been observed, inappropriate sinus tachycardia (IST) is a rare phenomenon. We aimed to investigate the prevalence and natural history of an abnormal sinus HR response after cryoballoon PVI. Methods We included 169/646 (26.2%) patients with AF undergoing PVI with available Holter recordings before and 3, 6 and 12 months after the procedure. Patients with AF on Holter monitoring were excluded. Mean HR increase ≥ 20 bpm or an IST-like pattern (mean HR > 90 bpm or > 80 bpm when beta-blocking agents were used) following PVI was categorised as abnormal sinus HR response. Results Following PVI, mean HR ± standard deviation increased in the entire group from 63.5 ± 8.4 to 69.1 ± 9.9 bpm at 3 months (p p p p = 0.033). However, in patients meeting IST-like pattern criteria, mean HR at 12 months was no longer significantly different from that pre-ablation. Conclusion Few patients had an abnormal sinus HR response after PVI. Peak HR was observed 3 months after PVI, but HR was still significantly increased 12 months post-ablation compared with pre-ablation. An IST-like pattern was rarely observed. In these patients, HR decreased to pre-ablation values within a year.

Background The development of atrial fibrillation (AF) is a complex multifactorial process. Over the past few decades, much has been learned about the pathophysiological processes that can lead to AF from a variety of specific disease models in animals. However, our ability to recognise these disease processes in AF patients is still limited, which has contributed to the limited progress in improving rhythm control in AF. Aims/objectives We believe that a better understanding and detection of the individual pathophysiological mechanisms underlying AF is a prerequisite for developing patient-tailored therapies. The RACE V Tissue Bank Project will contribute to the unravelling of the main molecular mechanisms of AF by studying histology and genome-wide RNA expression profiles and combining this information with detailed phenotyping of patients undergoing cardiac surgery. Methods As more and more evidence suggests that AF may occur not only during the first days but also during the months and years after surgery, we will systematically study the incidence of AF during the first years after cardiac surgery in patients with or without a history of AF. Both the overall AF burden as well as the pattern of AF episodes will be studied. Lastly, we will study the association between the major molecular mechanisms and the clinical presentation of the patients, including the incidence and pattern of AF during the follow-up period. Conclusion The RACE V Tissue Bank Project combines deep phenotyping of patients undergoing cardiac surgery, including rhythm follow-up, analysis of molecular mechanisms, histological analysis and genome-wide RNA sequencing. This approach will provide detailed insights into the main pathological alterations associated with AF in atrial tissue and thereby contribute to the development of individualised, mechanistically informed patient-tailored treatment for AF.

In the past 20 years the Netherlands-based RACE trials have investigated important concepts in clinical atrial fibrillation (AF). Their scope ranged from rhythm versus rate control to early or delayed cardioversion and also included early comprehensive management of AF in two trials, one focusing on early ‘upstream therapy’ and risk factor management and the other on integrated chronic nurse-led care. Studies were mostly triggered by simple clinical observations including futility of electrical cardioversion in persistent AF; many patients with permanent AF tolerating day-after-day ‘uncontrolled’ resting heart rates of up till 110 beats/min; patients being threatened more by vascular risks than AF itself; and insufficient guideline-based treatments for AF. Also the observation that recent-onset atrial fibrillation generally converts spontaneously, obviating cardioversion, triggered one of the studies. The RACE trials shifted a number of paradigms and by that could change the AF guidelines. The initial ‘shock-and-forget’ attitude made place for increased attention for anticoagulation, and in turn, broader vascular risks were recognised. In a nutshell, the adage eventually became: ‘look beyond the ECG, treat the patient’. Electronic supplementary material The online version of this article (10.1007/s12471-020-01476-0) contains supplementary material, which is available to authorized users.

Background Combined 'hybrid' thoracoscopic and percutaneous atrial fibrillation (AF) ablation is a strategy used to treat AF in patients with therapy-resistant symptomatic AF. We aimed to study efficacy and safety of single-stage hybrid AF ablation in patients with symptomatic persistent AF, or paroxysmal AF with failed endocardial ablation, and assess determinants of success and quality of life.Methods We included consecutive patients undergoing single-stage hybrid AF ablation. First, we performed epicardial ablation, via thoracoscopic access, to isolate the pulmonary veins and superior caval vein and to create a posterior left atrial box. Thereafter, isolation was assessed endocardially and complementary endocardial ablation was performed, followed by cavotricuspid isthmus ablation. Efficacy was assessed by 12-lead electrocardiography and 72-hour Holter monitoring after 3, 6 and 12 months. Recurrence was defined as AF/atrial flutter/tachycardia recorded by electrocardiography or Holter monitoring lasting >30s during 1-year follow-up.Results Fifty patients were included, 57 +/- 9 years, 38 (76%) men, 5 (10%) paroxysmal, 34 (68%) persistent and 11 (22%) long-standing persistent AF. At 1-year 38 (76%) maintained sinus rhythm off antiarrhythmic drugs. Majority of recurrences were atrial flutter (9/12 patients). Success was associated with type of AF (p = 0.039). Patients with paroxysmal AF had highest success, patients with longstanding persistent AF had lowest success. Seven (14%) patients had procedure-related complications. Quality of life improved after ablation in patients who maintained sinus rhythm.Conclusion Success of single-stage hybrid AF ablation was 76% off antiarrhythmic drugs, being associated with type of AF. Quality of life improved significantly, Procedure-related complications occurred in 14%.

Cardiovascular implantable electronic devices (CIEDs) can detect atrial arrhythmias, i.e. atrial high-rate episodes (AHRE). The thrombo-embolic risk in patients showing AHRE appears to be lower than in patients with clinical atrial fibrillation (AF) and it is unclear whether the former will benefit from oral anticoagulants. Based on currently available evidence, it seems reasonable to consider antithrombotic therapy in patients without documented AF showing AHRE >24 hours and a CHA(2)DS(2)-VASc score (congestive heart failure, hypertension, age >= 75 years [doubled], diabetes mellitus, prior stroke [doubled], vascular disease, age 65-74 years and female sex) >= 1, awaiting definite answers from ongoing randomised clinical trials. In patients with AHRE

Objectives This study evaluated the waiting list for elective electrical cardioversion (ECV) for persistent atrial fibrillation (AF), focusing on when and why procedures were postponed. We compared the effects of management of the waiting list conducted by physicians versus management by nurse practitioners (NPs) and we evaluated the safety of our anticoagulating policy by means of bleeding or thromboembolic complications during and after ECV. Background Not all patients selected for ECV receive their treatment at the first planned instance due to a variety of reasons. These reasons are still undocumented. Methods We evaluated 250 consecutive patients with persistent AF admitted to our clinic for elective ECV. Results Within 5 to 6 weeks, 186 of 242 patients (77%) received ECV. The main reason for postponing an ECV was an inadequate international normalised ratio (INR); other reasons included spontaneous sinus rhythm and switch to rate control. A total of 23 of the 147 patients (16%) managed by the research physician were postponed due to an inadequate INR at admission versus 4 out of 98 patients (4%) managed by NPs (p = 0.005) Conclusion An inadequate INR is the main reason for postponing an ECV. Management of ECV by NPs is safe and leads to less postponing on admission.