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Supplemental Digital Content is available in the text Introduction: There is conflicting evidence for the benefit of adjuvant radiotherapy (RT) after resection of pancreatic ductal adenocarcinoma (PDAC), especially for margin-negative (R0) resections. We aimed to evaluate the association of adjuvant RT with survival after R0 resection of PDAC. Methods: Using National Cancer Database (NCDB) data from 2004 to 2013, we identified patients with R0 resection of nonmetastatic PDAC. Patients with neoadjuvant radiotherapy and chemotherapy and survival <6 months were excluded. Propensity score matching was used to account for treatment selection bias. A multivariable Cox proportional hazards model was then used to analyze the association of RT with survival. Results: Of 4547 (36%) RT and 7925 (64%) non-RT patients, 3860 RT and 3860 non-RT patients remained in the cohort after matching. Clinicopathologic and demographic variables were well balanced after matching. Lymph node metastases were present in 68% (44% N1, 24% N2). After matching, RT was associated with higher survival (median 25.8 vs 23.9 mo, 5-yr 27% vs 24%, P < 0.001). After multivariable adjustment, RT remained associated with a survival benefit (HR 0.89, 95% CI 0.84–0.94, P < 0.001). Stratified and multivariable interaction analyses showed that this benefit was restricted to patients with node-positive disease: N1 (HR: 0.68, CI95%: 0.62–0.76, P = 0.007) and N2 (HR: 0.59, CI95%: 0.54–0.64, P = 0.04). Conclusions: In this large retrospective cohort study, adjuvant RT after R0 PDAC resection was associated with a survival benefit in patients with node-positive disease. Adjuvant RT should be considered after R0 resection of PDAC with node-positive disease. [ABSTRACT FROM AUTHOR]

Background: We have previously shown that the presence of dual muscular coronary sinus (CS) to left atrial (LA) connections, coupled with rate-dependent unidirectional block in one limb, is associated with atrial fibrillation (AF) induction. This study sought to examine whether ablation of distal CS to LA connections at a first AF ablation reduces arrhythmia recurrence during follow-up.Methods: In this single-center, randomized, controlled trial, 35 consecutive patients with drug-refractory AF undergoing first-time ablation between August 2018 and August 2019, were randomly assigned to (1) standard ablation (pulmonary vein isolation and nonpulmonary vein trigger ablation) versus (2) standard ablation plus elimination of distal CS to LA connections targeting the earliest LA activation during distal CS pacing with a deca-polar catheter placed with its proximal electrode at the ostium. Change of the local CS atrial electrogram and LA activation sequence to early activation of the LA septum or roof during distal CS pacing were the end point for CS-LA connection elimination.Results: Thirty patients completed 6 months study follow-up (15 patients in each group). Demographic characteristics including age and AF persistence were similar in both groups. After a mean follow-up of 170±22 days, there were 7 atrial arrhythmia recurrences in the standard group and 1 recurrence in the CS-LA connection elimination group (46.7% versus 6.7%, hazard ratio, 0.12, P=0.047).Conclusions: Elimination of distal CS to LA connections reduced atrial arrhythmia recurrences compared with standard pulmonary vein isolation and nonpulmonary vein trigger ablation in patients undergoing a first AF ablation procedure in a small randomized study. This strategy warrants further evaluation in a multicenter randomized trial. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03646643. [ABSTRACT FROM AUTHOR]

Background: Repolarization abnormalities in arrhythmogenic right ventricular (RV) cardiomyopathy and their relationship to ventricular tachycardia substrate are incompletely understood.Methods and Results: In 40 patients (29 men, mean age 38 years) with arrhythmogenic RV cardiomyopathy, we compared the extent and location of abnormal T (NegT) waves ≥1 mm in depth (n=32) and downsloping elevated ST segment (n=13), in ≥2 adjacent leads, to area and location of endocardial bipolar (<1.5 mV) and unipolar (<5.5 mV) and epicardial bipolar (<1.0 mV) voltage abnormalities. Abnormal unipolar RV endocardial area of 33.4±19.3% was present in 8 patients without NegT waves. Patients with NegT waves extending beyond lead V3 (n=20) had larger low bipolar (31.4±18.9% versus 16.5±14.6%; P=0.008) and unipolar endocardial areas (66.0±19.6% versus 47.4±25.1%; P=0.013) and larger epicardial low bipolar area (56.0±19.3% versus 40.1±24.9%; P=0.030) compared with those with NegT waves limited to leads V1 through V3 (n=20). ECG location of NegT waves regionalized to location of substrate. Patients with downsloping elevated ST segment, all localized to leads V1 and V2, had more unipolar endocardial abnormalities (71.8±18.1% versus 49.4±23.5%; P=0.005) involving outflow and mid-RV, compared with patients without downsloping elevated ST segment.Conclusions: In arrhythmogenic RV cardiomyopathy, abnormal electroanatomic mapping areas are proportional to extent of T-wave inversion on 12-lead ECG. Marked voltage abnormalities can exist without repolarization change. Downsloping elevated ST-segment pattern in V1 and V2 occurs with more unipolar endocardial voltage abnormality, consistent with more advanced transmural disease. [ABSTRACT FROM AUTHOR]

Background: Successful ventricular tachycardia (VT) ablation is associated with improved survival in patients with heart failure. However, the safety and efficacy of VT ablation in the elderly, a population with higher competing nonsudden death risk and comorbidities, have not been well defined.Methods and Results: The International Ventricular Tachycardia Center Collaborative Study Group registry of 2061 patients who underwent VT ablation at 12 international centers was analyzed. Kaplan-Meier analysis was used to estimate survival of patients ≥70 years with and without VT recurrence. Of the 2049 patients who met inclusion criteria, 681 (33%) patients were ≥70 years of age (mean age, 75±4 years). Among these, 92% were men, 71% had ischemic VT, and 42% had VT storm at presentation. Mean (±SD) left ventricular ejection fraction was 30±11%. Compared with patients <70 years, patients ≥70 years had higher in-hospital (4.4% versus 2.3%; P=0.01) and 1-year mortality (15% versus 11%; P=0.002) but a similar incidence of VT recurrence at 1 year (26% versus 25%; P=0.74) and time to VT recurrence (280 versus 289 days; P=0.20). Absence of VT recurrence during follow-up was strongly associated with improved survival in patients ≥70 years.Conclusion: VT ablation in the elderly is feasible and reasonably safe with a modestly higher in-hospital and 1-year mortality, with similar rates of VT recurrence at 1 year compared with younger patients. Successful VT ablation, that is, lack of VT recurrence, is strongly associated with improved survival even in this elderly subgroup. [ABSTRACT FROM AUTHOR]

Objectives: To document the existence of primary pancreatic secretinoma in patients with watery diarrhea syndrome (WDS) and achlorhydria and establish secretin as a diarrheogenic hormone. Background: Vasoactive intestinal peptide (VIP) has been widely accepted as the main mediator of WDS. However, in 1968, Zollinger et al reported 2 female patients with pancreatic neuroendocrine tumors, WDS, and achlorhydria. During surgery on the first, a 24-year-old patient, they noticed distended duodenum filled with fluid and a dilated gallbladder containing dilute bile with high bicarbonate concentration. After excision of the tumor, WDS ceased and gastric acid secretion returned. The second, a 47-year-old, patient's metastatic tumor extract given intravenously in dogs, produced significantly increased pancreatic and biliary fluid rich in bicarbonate. They suggested a secretin-like hormone of islet cell origin explains WDS and achlorhydria. These observations, however, predated radioimmunoassay, immunohistochemical staining, and other molecular studies. Methods: The first patient's tumor tissue was investigated for secretin and VIP. Using both immunohistochemistry and laser microdissection and pressure catapulting technique for RNA isolation and subsequent reverse transcription polymerase chain reaction, the expression levels of secretin, and VIP were measured. Results: Immunoreactive secretin and its mRNA were predominantly found in the tumor tissue whereas VIP and its mRNA were scarce. Conclusions: The findings strongly support that the WDS and achlorhydria in this patient may have been caused by secretin as originally proposed in 1968 and that secretin may act as a diarrheogenic hormone. [ABSTRACT FROM AUTHOR]

This study investigated racial differences in patient-physician communication around mental health versus biomedical issues. Data were collected from audiorecorded periodic health examinations of adults with mental health needs in the Detroit area (2007-2009). Patients and their primary care physicians conversed for twice as long, and physicians demonstrated greater empathy during mental health topics than during biomedical topics. This increase varied by patient and physician race. Patient race predicted physician empathy, but physician race predicted talk time. Interventions to improve mental health communication could be matched to specific populations based on the separate contributions of patient and physician race. [ABSTRACT FROM AUTHOR]

Background: Ventricular tachycardia (VT) radiofrequency ablation has been associated with reduced VT recurrence and mortality, although it is typically not considered among New York Heart Association class IV (NYHA IV) heart failure patients. We compared characteristics and VT radiofrequency ablation outcomes of those with and without NYHA IV in the International VT Ablation Center Collaboration.Methods and Results: NYHA II-IV patients undergoing VT radiofrequency ablation at 12 international centers were included. Clinical variables, VT recurrence, and mortality were analyzed by NYHA IV status using Kaplan-Meier analysis and Cox proportional hazard models. There were significant differences between NYHA IV (n=111) and NYHA II and III (n=1254) patients: NYHA IV had lower left ventricular ejection fraction; more had diabetes mellitus, kidney disease, cardiac resynchronization implantable cardioverter-defibrillator, and VT storm despite greater antiarrhythmic drug use (P<0.01). NYHA IV subjects required more hemodynamic support, were inducible for more and slower VTs, and were less likely to undergo final programmed stimulation. There was no significant difference in acute complications. In-hospital deaths, recurrent VT, and 1-year mortality were higher in the NYHA IV group, in the context of greater baseline comorbidities. Importantly, NYHA IV patients without recurrent VT had similar survival compared with NYHA II and III patients with recurrent VT (68% versus 73%). Early VT recurrence (≤30 days) was significantly associated with mortality, especially in NYHA IV patients.Conclusions: Despite greater baseline comorbidities, VT radiofrequency ablation can be safely performed among NYHA IV patients. Early VT recurrence is significantly associated with subsequent mortality regardless of NYHA status. Elimination of recurrent VT in NYHA IV patients may reduce mortality to a level comparable to NYHA II and III with arrhythmia recurrence. [ABSTRACT FROM AUTHOR]

Background: Catheter ablation (CA) of ventricular tachycardia (VT) in patients with cardiac sarcoidosis can be challenging because of the complex underlying substrate. We sought to determine the long-term outcome of CA of VT in patients with cardiac sarcoidosis.Methods and Results: We enrolled 31 patients (age, 55±10 years) with diagnosis of cardiac sarcoidosis based on Heart Rhythm Society criteria and VT who underwent CA. In 23 (74%) patients, preprocedure cardiac magnetic resonance imaging and positron emission tomographic (PET) evaluation were performed. Preprocedure magnetic resonance imaging was positive for late gadolinium enhancement in 21 of 23 (91%) patients, whereas abnormal 18-fluorodeoxyglucose uptake was found in 15 of 23 (65%) cases. In 14 of 15 patients with positive PET at baseline, PET was repeated after 6.1±3.7-month follow-up. After a median follow-up of 2.5 (range, 0-10.5) years, 1 (3%) patient died and 4 (13%) underwent heart transplant. Overall VT-free survival was 55% at 2-year follow-up. Among the 16 (52%) patients with VT recurrences, CA resulted in a significant reduction of VT burden, with 8 (50%) having only isolated (1-3) VT episodes and only 1 patient with recurrent VT storm. The presence of late gadolinium enhancement at magnetic resonance imaging, a positive PET at baseline, and lack of PET improvement over follow-up were associated with increased risk of recurrent VT.Conclusions: In patients with cardiac sarcoidosis and VT, CA is effective in achieving long-term freedom from VT or improvement in VT burden in the majority of patients. The presence of late gadolinium enhancement at magnetic resonance imaging, a positive PET scan at baseline, or lack of improvement at repeat PET over follow-up predict worse arrhythmia-free survival. [ABSTRACT FROM AUTHOR]

Despite the global COVID-19 pandemic, during the past 2 years, there have been numerous advances in our understanding of arrhythmia mechanisms and diagnosis and in new therapies. We increased our understanding of risk factors and mechanisms of atrial arrhythmias, the prediction of atrial arrhythmias, response to treatment, and outcomes using machine learning and artificial intelligence. There have been new technologies and techniques for atrial fibrillation ablation, including pulsed field ablation. There have been new randomized trials in atrial fibrillation ablation, giving insight about rhythm control, and long-term outcomes. There have been advances in our understanding of treatment of inherited disorders such as catecholaminergic polymorphic ventricular tachycardia. We have gained new insights into the recurrence of ventricular arrhythmias in the setting of various conditions such as myocarditis and inherited cardiomyopathic disorders. Novel computational approaches may help predict occurrence of ventricular arrhythmias and localize arrhythmias to guide ablation. There are further advances in our understanding of noninvasive radiotherapy. We have increased our understanding of the role of His bundle pacing and left bundle branch area pacing to maintain synchronous ventricular activation. There have also been significant advances in the defibrillators, cardiac resynchronization therapy, remote monitoring, and infection prevention. There have been advances in our understanding of the pathways and mechanisms involved in atrial and ventricular arrhythmogenesis. [ABSTRACT FROM AUTHOR]