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Background Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist and share an increased risk of thromboembolic events. CKD concomitantly contributes to several pathophysiological changes predisposing towards a pro-haemorrhagic state. Objective To evaluate the impact of kidney function on peri-procedural complications and clinical outcomes in AF patients undergoing left atrial appendage occlusion (LAAO) with a Watchman device. Methods 2124 consecutive AF patients undergoing Watchman implantation at 8 different centers were categorized into CKD stage 1+2 (n=1089), CKD stage 3 (n=796), CKD stage 4 (n=170), CKD stage 5 (n=69) based on the estimated glomerular filtration rate at baseline. The primary efficacy endpoint included a composite of cardiovascular (CV) mortality, stroke, transient ischemic attack, peripheral thromboembolism (TE), and major bleeding. Results A non-significant higher incidence of major peri-procedural adverse events (1.7% vs. 2.3% vs. 4.1% vs. 4.3%) was observed with worsening baseline kidney function (p=0.14). The mean follow-up period was 13 ± 7 months [2226 patient-years (PY)]. In comparison to CKD stage 1+2 as a reference, the incidence of the primary endpoint was significantly higher in CKD stage 3 (log-rank p-value= 0.04), CKD stage 4 (log-rank p-value= 0.01), and CKD stage 5 (log-rank p-value= 0.001). A non-significant increase in event rates for stroke/TIA and clinically relevant bleeding was observed among the four groups. LAAO led to a TE risk reduction of 72%, 66%, 62%, and 41% in each group. The relative risk reduction in the incidence of major bleeding was 58%, 44%, 51%, and 52%, respectively. Conclusion Patients with moderate-to-severe CKD had a higher incidence of the primary composite endpoint. The relative risk reduction in the incidence of TE and major bleeding was consistent across CKD groups, irrespective of the very different risk profiles at baseline.

Background: Following left atrial appendage (LAA) electrical isolation, the decision on whether to continue oral anticoagulation after successful atrial fibrillation ablation is based on the study of its mechanical function on transesophageal echocardiography (TEE). In this cohort, LAA contraction is absent and the incorrect interpretation of emptying flow velocities can lead to unwanted clinical sequelae. Methods: One hundred and sixty consecutive TEE exams performed to evaluate the LAA mechanical function following its electrical isolation were reviewed by an experienced operator blinded to the original diagnosis of LAA dysfunction. The rate of diagnostic discrepancy in the assessment LAA dysfunction and its clinical implications were evaluated. Results: Diagnostic discrepancy with misclassification of the LAA mechanical function occurred 36% (58/160) of TEE exams. In most cases (57/58), such discrepancy was observed in the setting of an incorrect original diagnosis of a normal LAA mechanical function despite absent/reduced or inconsistent LAA contraction. This main source of this wrong diagnosis was the wrong interpretation of passive LAA flows (34/57; 60%), followed by failure to identify dissociated firing (15/57; 26%). In rare cases (8/57; 14%), velocities of surrounding structures were interpreted as LAA flow due to misplacement of the pulsed-wave Doppler sample volume. Following LAA isolation, the proportion of patients who experienced a cerebrovascular event while off oral anticoagulation due to the misclassification of their LAA mechanical function was 70% (7/10 [95% CI, 40%–89%]). Conclusions: Underdiagnosis of LAA mechanical dysfunction is common in TEEs performed following LAA electrical isolation, and it is associated with an increased risk of cerebrovascular events owing to oral anticoagulation discontinuation despite absent/reduced LAA contraction. Careful review of the TEE exam by an operator with specific expertise in LAA imaging and familiar with the functional implications of LAA isolation is necessary before interrupting oral anticoagulation in this cohort.

COVID-19 mainly affects the respiratory system but has been correlated with cardiovascular manifestations such as myocarditis, heart failure, acute coronary syndromes, and arrhythmias. Cardiac arrhythmias are the second most frequent complication affecting about 30% of patients. Several mechanisms may lead to an increased risk of cardiac arrhythmias during COVID-19 infection, ranging from direct myocardial damage to extracardiac involvement. The aim of this review is to describe the role of COVID-19 in the pathogenesis of cardiac arrhythmias and provide a comprehensive guidance for their monitoring and management.

Though infrequent, incomplete left atrial appendage closure (LAAC) may result from residual leaks. Percutaneous closure has been described though data is limited.We compiled a registry from four centers of patients undergoing percutaneous closure of residual leaks following LAAC via surgical means or with the Watchman device. Leak severity was classified as none (no leak), mild (1-2 mm), moderate (3-4 mm), or severe (≥5 mm). Procedural and clinical success was defined as the elimination of leak or mild residual leak at the conclusion of the procedure or follow-up, respectively.Of 72 (age 72.2 ± 9.2 years; 67% male) patients, 53 had undergone prior LAAC using the Watchman device and 19 patients surgical LAAC. Mean CHADSPercutaneous closure of residual leaks following left atrial appendage closure is feasible and associated with good outcomes. The procedural risk appears to be satisfactory.

Aims Transesophageal echocardiography (TEE) is a standard peri-procedural imaging modality in patients undergoing percutaneous left atrial appendage (LAA) occlusion. An accurate device sizing is pivotal to assess stability and achieve successful closure. In this prospective study, we sought to evaluate the correlation between Watchman device compression rates (DCRs) and risk of incomplete LAA occlusion at follow-up in patients undergoing Watchman device implantation. Methods and results Two-dimensional TEE via a commercially available transducer (Vivid, Philips) was performed during the procedure and within 3 months after the procedure. LAA size, morphology, and DCRs [(original device size—size after deployment)/original device size; %] were assessed in a mid-oesophageal view at 0°, 45°, 90° and 135°, according to company recommendations. Residual leaks ≥ 3 mm were classified as significant. Between 2016 and 2018, 116 patients underwent LAA occlusion with a Watchman device at our institution. The mean age was 74 ± 9 years and 60.4% (n = 70) were males. The average CHA2DS2-VASc and HAS-BLED scores were 4.7 ± 1.7 and 2.5 ± 1.1, respectively. The final device size was 21 mm in 11 (9.5%) patients, 24 mm in 28 (24.1), 27 mm in 27 (23.3%), 30 mm in 26 (22.4%), and 33 mm in 24 (20.7). At follow-up TEE, 16 (13.8%) patients were found to have a significant (≥3 mm) residual leak. The average DCRs measured at different angles in patients with and without leak were not significantly different (24 ± 8% vs. 26 ± 7% at 0°, P = 0.47; 23 ± 9% vs. 25 ± 7% at 45°, P = 0.58; 23 ± 8% vs. 23 ± 6% at 90°, P = 0.61; 22 ± 8% vs. 21 ± 7% at 135°, P = 0.61). At receiver operating characteristic (ROC) analysis, the areas under the curve to discriminate between patients with/without leak were 0.58, 0.57, 0.55, and 0.46 for DCRs measured at 0°, 45°, 90°, and 135° angles. Conclusions Peri-procedural assessment of DCRs does not appear to be an accurate method to predict LAA complete occlusion in patients undergoing Watchman device implantation.

Aims A significant amount of atrial fibrillation patients does not receive appropriate anticoagulation, owing to contraindications and side effects. Octogenarians have higher competing comorbidities with a remarkable bleeding/thromboembolic (TE) risk. We aimed at analysing the clinical outcomes of LAAO compared with direct oral anticoagulation (DOAC) in octogenarians. Methods and results Data were extracted from two prospective databases including 488 LAAO and 825 DOAC patients. Patients aged 80 years or older accounted for 37.1% (n = 181) and 39.5% (n = 326). In order to attenuate the imbalance in covariates between the groups, a propensity score matching technique was used (covariates: age, sex, CHA2DS2-VASc, and HAS-BLED scores, follow-up duration; tolerance 0.02). This method resulted in matched populations with 108 octogenarian patients per group. The annual stroke/transient ischaemic attack (TIA) risk was estimated based on the CHA2DS2-VASc, and compared to the annualized observed risk, owing to calculate the % risk reduction associated with the two treatment strategies. A total of 216 octogenarians were included in the analysis (84 ± 3 years; CHA2DS2-VASc: 4.9 ± 1.4, HAS-BLED: 3.1 ± 0.9). A Watchman device was successfully deployed in all LAAO ≥ 80 patients; periprocedural adverse events were observed in 2.8% (n = 3) of LAAO patients. During a follow-up of 13 ± 4 months, 3 (2.8%) TE complications (1 stroke, 2 TIA) occurred in LAAO ≥ 80 pts and 4 (3.7%; 1 stroke, 3 TIA) in DOAC ≥ 80 pts (P = 0.99). The annualized risk of stroke/TIA was 2.5% in the first and 3.5% in the second group. Based on the estimated annual TE risk according to the CHA2DS2-VASc score, the % risk reduction after LAAO and DOAC was 54.5% and 36.4%, respectively. Major bleeding events were 3 [1 intracranial, 2 gastrointestinal (GI)] LAAO ≥ 80 pts, and 3 (2 intracranial, 1GI) in DOAC ≥ 80 pts (2.8% in both groups). Minor bleeding events were significantly higher in DOAC ≥ 80 pts [13.0% (n = 14) vs. 2.7% (n = 3); RR: 4.7, 95% CI: 1.4–15.7; P = 0.009]. Conclusions LAAO was safe and similar to DOAC at preventing ischaemic/major bleeding events in a matched population of patients aged ≥80 years. A significantly higher incidence of minor bleeding events was observed in the DOAC group.

Aims Left atrial appendage occlusion (LAAO) might be particularly attractive in chronic kidney disease (CKD) patients, owing to a high thromboembolic risk and an even higher risk of bleeding. We sought to evaluate the safety and effectiveness of LAAO in CKD patients. Methods and results A total of 1238 patients undergoing LAAO at six centres were enrolled. On the basis of kidney function, as assessed via the CKD-EPI formula, patients were classified in two groups. Group1 had a GFR value ≤60 ml/min/1.73 m2 (CKD stages 3a-b, 4, and 5), whereas Group2 had a function >60 ml/min/1.73 m2 (CKD stages 1 and 2). Predicted annual rates of TE or major bleeding events were compared to the annualized observed risk of the two populations. Compared to Group 2 (n = 720, 47.5% males), patients in Group 1 (n = 518, 86.5% males) were older (mean age: 78 ± 8 vs. 75 ± 8, P Conclusions LAAO is a safe and effective approach in CKD patients. Given the increased risk of bleeding and contraindications to oral anticoagulation, CKD patients might be good candidates for LAA occlusion.

Aims Despite advances in success rate of paroxysmal atrial fibrillation (PAF) ablation, outcomes of radiofrequency catheter ablation (RFCA) in patients with persistent AF are highly variable. Early persistent AF (EPsAF) is defined as AF that is sustained beyond 7 days but is less than 3 months in duration. Arrhythmia-free survival data after RFCA in this specific population are still limited. We sought to report the outcomes of RFCA in the subgroup of patients with EPsAF, compared to those with PAF and with ‘late’ persistent AF (LPsAF) lasting between 3 and 12 months. Methods and results Data from 1143 consecutive AF patients receiving their first RFCA were prospectively collected. Patients with EPsAF (n = 190) were compared with PAF (n = 531) and LPsAF (n = 422) patients. All patients received pulmonary vein antrum isolation + posterior wall and sustained non-pulmonary vein (PV) trigger ablation. Non-sustained non-PV triggers were ablated based on operator discretion. Non-PV triggers were defined as sites of firing leading to sustained (>30 s) or non-sustained arrhythmias ( Conclusions In patients with EPsAF, RFCA may result in significantly better freedom from atrial arrhythmias, compared to LPsAF. In this cohort, ablation might be reasonable as first line approach to improve outcomes and prevent AF progression.

Aims Left atrial appendage occlusion (LAAO) with the Watchman device is an effective alternative to oral anticoagulation in patients with non-valvular atrial fibrillation at high thromboembolic risk. We sought to evaluate the safety and effectiveness of LAAO for stroke and bleeding prevention in patients at very high stroke risk. Methods and results Data were extracted from a prospective database of 488 AF patients who underwent LAA closure with a Watchman device. Periprocedural complications, thromboembolic (TE), and bleeding event rates among patients with a CHA2DS2-VASc ≥ 5 were reported. Predicted annual rates of TE or major bleeding events were compared to the annualized observed risk of the population. Overall, 209 patients with a CHA2DS2-VASc ≥5 (CHA2DS2-VASc: 6.0 ± 1.0; HAS-BLED: 3.7 ± 1.1) were included in the study. The mean age was 78 ± 6 years and 52.2% (n = 109) were males. Watchman implantation was successful in all patients. Overall procedure-related complication rate was 3.3% (n = 7). Two major complications were observed (1.0%): one pericardial tamponade requiring surgery and one major bleeding event at 3 days post-procedure. The incidence of minor complications was 2.3% (n = 5). Specifically, two patients experienced a pericardial effusion that required drainage and three had a groin hematoma. During a mean follow-up duration of 12 ± 5 months (193 pt/years), six TE events (2.9%/annualized rate: 3.1%) were documented after a median of 6.3 months (IQR: 2.2–9.6). Based on the estimated annual TE risk according to the CHA2DS2-VASc score (8.5%), the % risk reduction after LAAO was 63.5%. Four major bleeding events [1.9% (median time to event: 2.1 months; IQR: 1.0–3.4)] and five minor bleeding events occurred (2.5%) during follow-up. Compared to the expected rate of bleeding events as assessed by the HAS-BLED of the population (8.03%), LAAO led to a 42% reduction of bleeding risk. Conclusions In a population at very high TE risk, LAAO with the Watchman device was a safe and effective approach, and led to a 63.5% of stroke risk.

Patients undergoing catheter ablation for atrial fibrillation (AF) are routinely admitted for observation overnight in the hospital. With the rising incidence of AF among the population, increased volumes of procedures are placing increased demands on hospital resources. The purpose of this study was to evaluate the efficacy and safety of same day discharge in patients undergoing ablation for AF when compared to patients admitted for overnight observation. We performed a retrospective analysis using a multicenter cohort among patients who were discharged home after elective pulmonary vein isolation (PVI) ablation for AF. In our analysis, we found no statistically significant difference between patients discharged on the day of their procedure when compared to patients admitted for overnight observation in terms of 90-day readmission, major adverse cardiovascular events and death. This study shows that same day discharge after AF ablation is a feasible option. Future studies are needed to elicit the appropriate protocol to use.

After ablation when the pulmonary veins are isolated from the prior procedure, non-pulmonary vein triggers should be considered.

Entrainment mapping can be challenging due to acceleration of tachycardia. The use of activation and entrainment is useful in combination. Non-pulmonary vein trigger ablation can be helpful in achieving success with ablation.

During ablation of persistent atrial fibrillation, the rhythm can often organize to atrial flutter. Electroanatomic mapping can sometimes be a challenge due to low voltage. Entrainment of stable tachycardias is useful in these situations.

Remote Navigation of Circular Mapping Catheters Introduction Circular mapping catheters (CMC) are an essential tool in most atrial fibrillation ablation procedures. The Vdrive™ with V-Loop™ system enables a physician to remotely manipulate a CMC during electrophysiology studies. Our aim was to compare the clinical performance of the system to conventional CMC navigation according to efficiency and safety endpoints. Methods and Results A total of 120 patients scheduled to undergo a CMC study followed by pulmonary vein isolation (PVI) were included. Treatment allocation was randomized 2:1, remote navigation:manual navigation. The primary effectiveness endpoint was assessed based on both successful navigation to the targeted pulmonary vein (PV) and successful recording of PV electrograms. All PVs were treated independently within and between patients. The primary safety endpoint was assessed based on the occurrence of major adverse events (MAEs) through seven days after the study procedure. Primary effectiveness endpoints were achieved in 295/302 PVs in the Vdrive arm (97.7%) and 167/167 PVs in the manual arm (100%). Effectiveness analysis indicates Vdrive non-inferiority (pnon-inferiority = 0.0405; δ = –0.05) per the Cochran–Mantel–Haenszel test adjusted for PV correlation. Five MAEs related to the ablation procedure occurred (three in the Vdrive arm—3.9%; two in the manual arm—2.33%). No device-related MAEs were observed; safety analysis indicates Vdrive non-inferiority (pnon-inferiority = 0.0441; δ = 0.07) per the normal Z test. Conclusion Remote navigation of a CMC is equivalent to manual in PVI in terms of safety and effectiveness. This allows for single-operator procedures in conjunction with a magnetically guided ablation catheter.