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OBJECTIVE: Implantable cardiac defibrillators (ICD) implantation in the very elderly remains controversial. We aimed to describe the experience and outcome of patients over 80 years old implanted with an ICD in Belgium. METHODS: Data were extracted from the national QERMID-ICD registry. All implantations performed in octogenarians between February 2010 and March 2019 were analysed. Data on baseline patient characteristics, type of prevention, device configuration and all-cause mortality were available. To determine predictors of mortality, multivariable Cox proportional hazard regression modelling was performed. RESULTS: Nationwide, 704 primo ICD implantations were performed in octogenarians (median age 82, IQR 81-83 years; 83% male and 45% secondary prevention). During a mean follow-up of 3.1 ± 2.3 years, 249 (35%) patients died, of which 76 (11%) within the first year after implantation. In multivariable Cox regression analysis age (HR = 1.15, P = 0.004), oncological history (HR = 2.43, P = 0.027) and secondary prevention (HR = 2.23, P = 0.001) were independently associated with 1-year mortality. A better preserved left ventricular ejection fraction (LVEF) was associated with a better outcome (HR = 0.97, P = 0.002). Regarding overall mortality multivariable analysis withheld age, history of atrial fibrillation, centre volume and oncological history as significant predictors. Higher LVEF was again protective (HR = 0.99, P = 0.008). CONCLUSIONS: Primary ICD implantation in octogenarians is not often performed in Belgium. Among this population, 11% died within the first year after ICD implantation. Advanced age, oncological history, secondary prevention and a lower LVEF were associated with an increased one-year mortality. Age, low LVEF, atrial fibrillation, centre volume and oncological history were indicative of higher overall mortality.

BACKGROUND Direct-acting oral anticoagulant use for stroke prevention in atrial fibrillation is limited by bleeding concerns. Asundexian, a novel, oral small molecule activated coagulation factor XIa (FXIa) inhibitor, might reduce thrombosis with minimal effect on haemostasis. We aimed to determine the optimal dose of asundexian and to compare the incidence of bleeding with that of apixaban in patients with atrial fibrillation. METHODS In this randomised, double-blind, phase 2 dose-finding study, we compared asundexian 20 mg or 50 mg once daily with apixaban 5 mg twice daily in patients aged 45 years or older with atrial fibrillation, a CHA2DS2-VASc score of at least 2 if male or at least 3 if female, and increased bleeding risk. The study was conducted at 93 sites in 14 countries, including 12 European countries, Canada, and Japan. Participants were randomly assigned (1:1:1) to a treatment group using an interactive web response system, with randomisation stratified by whether patients were receiving a direct-acting oral anticoagulant before the study start. Masking was achieved using a double-dummy design, with participants receiving both the assigned treatment and a placebo that resembled the non-assigned treatment. The primary endpoint was the composite of major or clinically relevant non-major bleeding according to International Society on Thrombosis and Haemostasis criteria, assessed in all patients who took at least one dose of study medication. This trial is registered with ClinicalTrials.gov, NCT04218266, and EudraCT, 2019-002365-35. FINDINGS Between Jan 30, 2020, and June 21, 2021, 862 patients were enrolled. 755 patients were randomly assigned to treatment. Two patients (assigned to asundexian 20 mg) never took any study medication, resulting in 753 patients being included in the analysis (249 received asundexian 20 mg, 254 received asundexian 50 g, and 250 received apixaban). The mean age of participants was 73·7 years (SD 8·3), 309 (41%) were women, 216 (29%) had chronic kidney disease, and mean CHA2DS2-VASc score was 3·9 (1·3). Asundexian 20 mg resulted in 81% inhibition of FXIa activity at trough concentrations and 90% inhibition at peak concentrations; asundexian 50 mg resulted in 92% inhibition at trough concentrations and 94% inhibition at peak concentrations. Ratios of incidence proportions for the primary endpoint were 0·50 (90% CI 0·14-1·68) for asundexian 20 mg (three events), 0·16 (0·01-0·99) for asundexian 50 mg (one event), and 0·33 (0·09-0·97) for pooled asundexian (four events) versus apixaban (six events). The rate of any adverse event occurring was similar in the three treatment groups: 118 (47%) with asundexian 20 mg, 120 (47%) with asundexian 50 mg, and 122 (49%) with apixaban. INTERPRETATION The FXIa inhibitor asundexian at doses of 20 mg and 50 mg once daily resulted in lower rates of bleeding compared with standard dosing of apixaban, with near-complete in-vivo FXIa inhibition, in patients with atrial fibrillation. FUNDING Bayer.

BACKGROUND There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS). OBJECTIVES This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey. METHODS Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention. RESULTS A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001). CONCLUSIONS A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians. (J Am Coll Cardiol 2021;78:2131-2143) (c) 2021 by the American College of Cardiology Foundation.

Case description : A 74-year-old man suffering from severe heart failure (NYHA III – LVEF 28%) associated with left bundle branch block (LBBB) (Figure 1(A)) and uncontrolled permanent atrial fibrillation (AF) despite optimal medical treatment was referred for His ablation and rescue physiological pacing after a first unsuccessful LV lead implantation through the coronary sinus (CS). Careful review of the occluded CS angiogram indeed revealed no side branches. Concordantly, the patient was offered a ‘rescue’ HBP procedure. Using the SelectSecure lead (model 3830) and a C315 His sheath (Both Medtronic, Inc. MN), His mapping (HV ¼ 106ms) and recruitment were easily obtained, unfortunately without LBBB correction.

This subanalysis of the Euro-CRT survey II specifically focus on Belgian practice for CRT implantation. It explores Belgian adherence with the guidelines but also benchmark CRT practice in Belgium against the other European countries. Overall, Belgian management of CRT implantation is performed with great agreement with guidelines. This report could be used to provide guidance for both practical and economical approaches.

Aims We sought to evaluate the efficacy and the safety of a simple technique for stabilizing the ablation catheter during anterior pulmonary vein (PV) encirclement in patients ablated for paroxysmal atrial fibrillation. This consisted of bending the ablation catheter in the left atrium, creating a loop that was cautiously advanced together with the long sheath at the ostium and then within the left superior PV. The curve was then progressively released to reach a stable contact with the anterior part of the left PVs. Methods and results Eighty consecutive patients (age 64 ± 11 years, left atrial diameter 43 ± 8 mm) undergoing ‘CLOSE’-guided PV isolation were prospectively randomized into two groups depending on whether the loop technique was used or not. When using the loop technique, the encirclement of the left PVs was shorter [20 min (interquartile range, IQR 17–24) vs. 26 min (IQR 18–33), P Conclusion This study describes a simple technique to facilitate catheter stability at the anterior part of the left PVs, resulting in more efficient left PV encirclement without compromising safety.

Objectives: Directed graph-mapping (DGM) is a novel operator-independent automatic tool that can be applied to the identification of the atrial tachycardia (AT) mechanism. In the present study, for the first time, DGM was applied in complex AT cases, and diagnostic accuracy was evaluated. Background: Catheter ablation of ATs still represents a challenge, as the identification of the correct mechanism can be difficult. New algorithms for high-density activation mapping (HDAM) render an easier acquisition of more detailed maps; however, understanding of the mechanism and, thus, identification of the ablation targets, especially in complex cases, remains strongly operator-dependent. Methods: HDAMs acquired with the latest algorithm (COHERENT version 7, Biosense Webster, Irvine, California) were interpreted offline by 4 expert electrophysiologists, and the acquired electrode recordings with corresponding local activation times (LATs) were analyzed by DGM (also offline). Entrainment maneuvers (EM) were performed to understand the correct mechanism, which was then confirmed by successful ablation (13 cases were centrifugal, 10 cases were localized re-entry, 22 cases were macro–re-entry, and 6 were double-loops). In total, 51 ATs were retrospectively analyzed. We compared the diagnoses made by DGM were compared with those of the experts and with additional EM results. Results: In total, 51 ATs were retrospectively analyzed. Experts diagnosed the correct AT mechanism and location in 33 cases versus DGM in 38 cases. Diagnostic accuracy varied according to different AT mechanisms. The 13 centrifugal activation patterns were always correctly identified by both methods; 2 of 10 localized reentries were identified by the experts, whereas DGM diagnosed 7 of 10. For the macro–re-entries, 12 of 22 were correctly identified using HDAM versus 13 of 22 for DGM. Finally, 6 of 6 double-loops were correctly identified by the experts, versus 5 of 6 for DGM. Conclusions: Even in complex cases, DGM provides an automatic, fast, and operator-independent tool to identify the AT mechanism and location and could be a valuable addition to current mapping technologies. © 2021 The Authors. Dr. Lorenzo is an employee of Biosense Webster. Dr. Goedgebeur is funded with a research grant of the Research Foundation Flanders/Fonds voor Wetenschappelijk Onderzoek (FWO). Dr. Strisciuglio is supported by a research grant from the Cardiopath PhD program. Dr. el Haddad is a consultant for Biosense Webster. Dr. Duytschaever is a consultant for Biosense Webster. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Background: CLOSE-guided atrial fibrillation (AF) ablation is based on contiguous (intertag distance ≤6 mm), optimized (Ablation Index >550 anteriorly and >400 posteriorly) point-by-point radiofrequency lesions. The optimal radiofrequency power remains unknown. Methods: The POWER-AF study is a prospective, randomized controlled monocentric study including patients with paroxysmal AF, planned for first CLOSE-guided pulmonary vein isolation using a contact force radiofrequency catheter (Thermocool SmartTouch, Biosense Webster, Inc, Irvine, CA). A total of 100 patients were randomized into 2 groups (1:1). The control group received AF ablation using the standard CLOSE protocol (35 W), whereas in the experimental group, pulmonary vein isolation was performed using high power (45 W). Endoscopic evaluation was performed in patients with intraesophageal temperature rise >38.5 °C. Results: The resulting sample size was 96 (48+48) patients. In the high power group, shorter procedure time (80 versus 102 minutes, P P P P P =0.31) showed an ulcerative perforation in a high power group patient (treated by endoscopic stenting and normalization after ≈4 months) and a superficial ulcerative lesion in a control group patient (conservative treatment). Both occurred following excessive Ablation Index applications (up to 460 and 480, respectively) with excessive contact force (30 g on average, with peaks up to 50 g). Six-months AF recurrence was not significantly different (10% in high power versus 8% in control, P =0.74). Conclusions: This randomized controlled study shows that a 45 W radiofrequency power CLOSE protocol in patients with paroxysmal AF significantly increases the global procedural efficiency with similar midterm efficacy. However, our study showed a narrower safety margin and a limited increased efficiency at the posterior wall using high power. This advocates against the use of high power in the region neighboring the esophagus.

Introduction: The impact of gender on ICD implantation practice and survival remain a topic of controversy. We analysed differences between men and women in patients implanted with an ICD in Belgium. Methods: The Belgian governmental health care institution (RIZIV/INAMI) keeps track of every ICD implantation by a digital registry. Participation is mandatory for reimbursement. From this registry, we analysed all new ICD implantations between 01/02/2010 and 31/01/2019 in Belgian patients. We compared men with women for baseline patient characteristics. We used a Chi 2 test for categorical variables (NYHA class, primary vs secondary prevention, underlying heart disease, type of device, QRS duration, presence of atrial fibrillation, diabetes and other comorbidity, center volume, population density and average income of the area of residency) and a Mann-Whitney U test for continuous variables [age and ejection fraction(EF)]. We used the Bonferroni method to correct for multiple testing. Secondly, we performed a Kaplan-Meier analysis. At last, we performed a multivariate logistic regression for 3-year and total mortality. Results: Only 3146 (20.8%) on 14747 implantations were in women. Women were significantly younger and had a better EF compared to men. Except for oncological history, women had less comorbidities (table 1). More women functioned in NYHA class > II and had a QRS > 150ms, which was consistent with a higher CRT-D vs VVI/DDD ratio. Kaplan-Meier showed a survival benefit in women (log-rank, p= Conclusions: Only a minority of patients implanted with a new ICD in Belgium are women. Their clinical profile differs from men. Their long-term survival is better, which can in part be explained by differences in indications and comorbidities.

Introduction: According to guidelines ICD implantation should not be performed in patients with an expected survival less than 1 year. We investigated how useful validated risk scores are to predict 1-y mortality after ICD implantation in patients with ischemic heart disease (IHD). Methods: The QERMID-ICD registry, managed by the Belgian health authorities, contains data of all patients implanted with an ICD. Participation is mandatory for reimbursement. We analyzed all new implantations between 01/02/2010 and 31/01/2018 in Belgian IHD patients. Data is available about age, gender, ejection fraction (EF), NYHA class, type of prevention, type of device, QRS duration, center volume, comorbidities and socio-economic status based on the area of residency. We performed a Cox proportional hazard regression and applied a modified version of the MADIT- (Goldenberg et al., JACC 2008) risk score (reported renal failure instead of BUN > 26mg%) and AAACC (Nevzorov et al., JCE 2018) risk score (no data on anemia, so AACC score) to predict 1-y mortality. Results: On a total of 6320 IHD patients, the 1-y mortality was 5.7%. Patients who died within 1 year were significantly older (70.9 vs 65.9 years), had a worse EF (28.7 vs 31.5%) and differed in most comorbidities. In the Cox model age, worse EF, secondary prevention, VVI/DDD devices, atrial fibrillation, COPD, neurological antecedents and renal failure were independent predictors of 1-y mortality (table 1). Area under ROC was comparable for the modified Goldenberg and AACC score (0.647 vs 0.652). With a cut-off of 5 on the modified Goldenberg and 7 on the AACC-score a positive predictive value (PPV) of respectively 15.5% an 17.4% and negative predictive value of 94.2% and 94.7% were obtained. Conclusion: Despite significant differences in baseline characteristics, selection of patients not suitable for ICD implantation (because of high 1-y mortality risk) can only be slightly improved by using simple risk scores due to their low PPV.

Introduction In Belgium ICD implantation is restricted to 23 centers. A previous analysis of our group based on aggregated results per center showed that 3y mortality varied significantly between centers ranging from 7.5 to 23.4%. Multivariate analysis demonstrated that volume, infection rate and a higher proportion of implantations in primary prevention were predictors of 3y-mortality. These findings needed to be confirmed on a patient level since they could be caused by inter-patient rather than inter-hospital differences. Methods The QERMID-ICD database is a retrospective database of all patients implanted with an ICD in Belgium managed by the governmental health care institution (RIZIV/INAMI). Participation is mandatory for reimbursement. We analyzed data of 9896 new implantations performed between 2010 and 2016. Following patient characteristics were available: demographics (gender, NYHA class, primary vs secondary prevention, underlying heart disease, type of device, QRS duration, age and ejection fraction (EF)), comorbidities (atrial fibrillation, diabetes, COPD, neurological disease, oncological disease and renal failure), volume of center (low < median of 65 primo-implantations/year vs high >65 implantations/year) and the average income of the arrondissement in which the patient lived (low income < p25, median p25-p75, high > p75). The primary endpoint was 3y-mortality. Chi-squared test and Mann-Whitney U test with correction for multiple testing were used and multivariate logistic regression was performed to determine the corrected odds ratio for 3-year mortality. Finally, Kaplan-Meier survival analysis was performed. Results Low volume centers treated different patients than high volume centers. They implant more primary prevention (66.5 vs. 61.6%), more often patients with ischemic cardiomyopathy (49.8 vs 47.9%), less often arrhythmogenic heart disease (13.2 vs 16.6%) and patients with more co-morbidities and from communities with lower average income. High volume centers used more cardiac resynchronization therapy (26.8 vs 22.5%) despite no difference in QRS width. 1 and 3-y mortality were significantly higher in the low volume centers, respectively 5.6 vs. 4.4% and 16 vs. 11.1%. This was also confirmed in Kaplan Meier survival analysis. In multivariate logistic regression underlying heart disease, income, age, EF, NYHA class, CRT, indication and most comorbidities were significantly associated with mortality, but center volume remained an independent risk factor for 3-y mortality (OR = 0.749 (0.702–0.937), p Conclusion Patients treated in low and high-volume centers in Belgium are different. However, there remained an association between volume and mortality of centers when controlling for these differences. Further research to elucidate if this association is due to statistical limitations of our analysis, referral bias or differences in quality of care is necessary. Funding Acknowledgement Type of funding source: None

Aims Catheter ablation of paroxysmal atrial fibrillation (AF) reduces AF recurrence, AF burden, and improves quality of life. Data on clinical and procedural predictors of arrhythmia recurrence are scarce and are flawed by the high rate of pulmonary vein reconnection evidenced during repeat procedures after pulmonary vein isolation (PVI). In this study, we identified clinical and procedural predictors for AF recurrence 1 year after CLOSE-guided PVI, as this strategy has been associated with an increased PVI durability. Methods and results Patients with paroxysmal AF, who received CLOSE-guided PVI and who participated in a prospective trial in our centre, were included in this study. Uni- and multivariate models were plotted to find clinical and procedural predictors for AF recurrence within 1 year. Three hundred twenty-five patients with a mean age of 63 years (CHA2DS2VASc 1 [1–3], left atrium diameter 41 ± 6 mm) were included. About 60.9% were male individuals. After 1 year, AF recurrence occurred in 10.5% of patients. In a binary logistic regression analysis, the diagnosis-to-ablation time (DAT) was found to be the strongest predictor of AF recurrence (P = 0.011). Diagnosis-to-ablation time ≥1 year was associated with a nearly two-fold increased risk for developing AF recurrence. Conclusion The DAT is the most important predictor of arrhythmia recurrence in low-risk patients treated with durable pulmonary vein isolation for paroxysmal AF. Whether reducing the DAT could improve long-term outcomes should be investigated in another trial.

Aims: “CLOSE”-guided pulmonary vein isolation (PVI) is based on contiguous (≤6 mm) and optimized radiofrequency (RF) ablation lesions (ablation index [AI] ≥ 400 posteriorly and ≥ 550 anteriorly]. However, the optimal RF power to reach the desired AI is unknown. Therefore we evaluated the efficiency of an ablation strategy using higher power (40 W) during a first “CLOSE”-guided PVI. Methods: Eighty consecutive patients undergoing “CLOSE”-guided PVI for symptomatic paroxysmal atrial fibrillation were ablated with 40 W (group A). Results were compared with 105 consecutive patients enrolled in the “CLOSE to CURE”-study and were ablated using the same protocol with 35 W (group B). Results: In group A, ablation was associated with shorter ablation procedure time (91 vs 111 minutes; P .733) were similar in both groups (groups A and B, respectively). No complications occurred. In group A, a gastroscopy—performed in five patients with esophageal temperature rise more than 42°C—did not reveal any esophageal lesion. Postprocedural recurrence of atrial tachyarrhythmia at 1 year was not significantly different between both groups. Conclusions: Using the “CLOSE”-protocol, increased power increases the efficiency of PVI without compromising patients' safety., SCOPUS: ar.j, info:eu-repo/semantics/published

Biventricular pacing (BVP) has been demonstrated to improve functional outcomes and mortality of patients with symptomatic heart failure, reduced LVEF and wide QRS. Unfortunately, difficult coronary sinus anatomy can limit left ventricular lead placement. In such clinical situation, His Bundle Pacing (HBP) and Left Bundle Branch Area Pacing (LBBAP) have recently appeared as attractive alternatives to BVP. We describe the case of a patient with an indication for Cardiac Resynchronization Therapy (CRT) and AV node ablation, where left ventricular lead implantation and corrective HBP failed. LBBAP allowed for electrical and echocardiographic resynchronization with significant functional improvement.

During the coronavirus disease (COVID-19) pandemic, cardiologists have attempted to minimize risks to their patients by using telehealth to provide continuing care. Rapid implementation of video consultations in outpatient clinics for patients with heart disease can be challenging. We employed a design thinking tool called a customer journey to explore challenges and opportunities when using video communication software in the cardiology department of a regional hospital. Interviews were conducted with 5 patients with implanted devices, a nurse, an information technology manager and two cardiologists. Three lessons were identified based on these challenges and opportunities. Attention should be given to the ease of use of the technology, the meeting features, and the establishment of the connection between the cardiologist and the patient. Further, facilitating the role of an assistant (or virtual assistant) with the video consultation software who can manage the telehealth process may improve the success of video consultations. Employing design thinking to implement video consultations in cardiology and to further implement telehealth is crucial to build a resilient health care system that can address urgent needs beyond the COVID-19 pandemic.

UNSTRUCTURED During the coronavirus disease (COVID-19) pandemic, cardiologists have attempted to minimize risks to their patients by using telehealth to provide continuing care. Rapid implementation of video consultations in outpatient clinics for patients with heart disease can be challenging. We employed a design thinking tool called a customer journey to explore challenges and opportunities when using video communication software in the cardiology department of a regional hospital. Interviews were conducted with 5 patients with implanted devices, a nurse, an information technology manager and two cardiologists. Three lessons were identified based on these challenges and opportunities. Attention should be given to the ease of use of the technology, the meeting features, and the establishment of the connection between the cardiologist and the patient. Further, facilitating the role of an assistant (or virtual assistant) with the video consultation software who can manage the telehealth process may improve the success of video consultations. Employing design thinking to implement video consultations in cardiology and to further implement telehealth is crucial to build a resilient health care system that can address urgent needs beyond the COVID-19 pandemic.

Objectives This study sought to evaluate the safety and the acute and 1 year outcomes of an ablation protocol aiming to enclose the PV with a contiguous and optimized RF circle by targeting region-specific criteria for lesion depth assessed by ablation index and interlesion distance. Background Reconnections after pulmonary vein (PV) isolation are explained by insufficient lesion depth and/or discontiguity of radiofrequency (RF) lesions. Methods A total of 130 consecutive patients with paroxysmal atrial fibrillation (AF) underwent PV encircling using a contact force–sensing catheter. RF was delivered targeting interlesion distance ≤6 mm and ablation index ≥400 at posterior wall and ≥550 at anterior wall. Recurrence was defined as any AF, atrial tachycardia (AT), or atrial flutter (AFL) (AF/AT/AFL >30 s) on Holter electrocardiographs at 3, 6, and 12 months. Results Procedure and RF time per circle were 155 ± 28 min and 17 ± 5 min, respectively. Incidence of first-pass and adenosine-proof isolation were 98% and 98%, respectively. One short-lived transient ischemic attack was observed. At 12 months, single-procedure freedom from AF/AT/AFL was 91.3% in those 104 patients off antiarrhythmic drug therapy and 96.2% in those 26 patients on antiarrhythmic drug therapy. Single-procedure freedom from both AF/AT/AFL and antiarrhythmic drug therapy was 73.1%. Conclusions This study suggests that an ablation protocol respecting strict criteria for lesion depth and contiguity results in acute durable PV isolation followed by a high single-procedure arrhythmia-free survival at 1 year. A prospective, multicenter trial is ongoing.

Aims Non-invasive electrocardiogram (ECG) mapping allows the activation of the entire atrial epicardium to be recorded simultaneously, potentially identifying mechanisms critical for atrial fibrillation (AF) persistence. We sought to evaluate the utility of ECG mapping as a practical tool prior to ablation of persistent AF (PsAF) in centres with no practical experience of the system. Methods and results A total of 118 patients with continuous AF duration

During the ESC congress in September 2019 in Paris, the new ESC guidelines were presented and are now available on the ESC website. The new guidelines describe management recommendations on following cardiovascular diseases: chronic coronary syndromes, acute pulmonary embolism, supraventricular tachycardia and dislipidaemias. The present document gives a summary of these guidelines and highlights the most important recommendations and changes in the management of these diseases. It will help to increase awareness about the new guidelines and may stimulate to consult the full document for specific items. Ultimately, the authors hope that this document will enhance implementation of new ESC guidelines in daily clinical practice.

Background: Few studies evaluated the impact of catheter ablation (CA) on atrial tachyarrhythmia (ATA) burden in paroxysmal atrial fibrillation (AF). Objective: In the prospective, patient-controlled CLOSE to CURE study, we determined the longer-term impact of optimized CA on ATA burden by using an insertable cardiac monitor (ICM). Methods: A total of 105 patients with paroxysmal AF were implanted with an ICM 65 (interquartile range [IQR] 61–78) days before CA. CA consisted of contact force–guided pulmonary vein isolation targeting an intertag distance of ≤6 mm and a region-specific ablation index. The primary end point was reduction in ICM-detected ATA burden; secondary end points were single-procedure freedom from ATA, quality of life, and adverse events. Results: The mean age was 62 ± 8 years; the median CHA2DS2-VASc score was 1 (IQR 1–2); and the median left atrial diameter was 43 (IQR 39–43) mm. After pulmonary vein isolation (1.13 ± 0.39 procedures per patient), median ATA burden decreased from 2.68% (IQR 0.09%–15.02%) at baseline to 0% (IQR 0%–0%) during the first year and to 0% (IQR 0%–0%) during the second year (reduction in ATA burden 100% [IQR 100%–100%]; P < .001). Single-procedure freedom from any ATA was 87% at 1 year and 78% at 2 years. Quality of life improved significantly across all scores. Adverse events occurred in 5 patients (4.8%). Conclusion: CA has become an effective procedure in paroxysmal AF, with a major impact on ICM-detected ATA burden. Whereas conventional survival analysis suggests a progressive decline in efficacy, we observed that burden reduction is maintained at longer follow-up. These data imply that ATA burden is a more optimal end point for assessing ablation efficacy.

Aims Overall, 40% of patients with atrial fibrillation are asymptomatic. The usefulness and cost-effectiveness of atrial fibrillation screening programmes are debated. We evaluated whether an atrial fibrillation screening programme with a handheld electrocardiogram (ECG) machine in a population-wide cohort has a high screening yield and is cost-effective. Methods We used a Markov-model based modelling analysis on 1000 hypothetical individuals who matched the Belgian Heart Rhythm Week screening programme. Subgroup analyses of subjects ≥65 and ≥75 years old were performed. Screening was performed with one-lead ECG handheld machine Omron® HeartScan HCG-801. Results In both overall population and subgroups, the use of the screening procedure diagnosed a consistently higher number of diagnosed atrial fibrillation than not screening. In the base-case scenario, the screening procedure resulted in 106.6 more atrial fibrillation patient-years, resulting in three fewer strokes, 10 more life years and five more quality-adjusted life years (QALYs). The number needed-to-screen (NNS) to avoid one stroke was 361. In subjects ≥65 years old, we found 80.8 more atrial fibrillation patient-years, resulting in three fewer strokes, four more life-years and five more QALYs. The NNS to avoid one stroke was 354. Similar results were obtained in subjects ≥75 years old, with a NNS to avoid one stroke of 371. In the overall population, the incremental cost-effectiveness ratio for any gained QALY showed that the screening procedure was cost-effective in all groups. Conclusions In a population-wide screening cohort, the use of a handheld ECG machine to identify subjects with newly diagnosed atrial fibrillation was cost-effective in the general population, as well as in subjects ≥65 and subjects ≥75 years old.

Summary: Background: Time delay between onset of symptoms and seeking medical attention is a major determinant of mortality and morbidity in patients with acute coronary artery occlusion. Response time might be reduced by reliable self-detection. We aimed to formally assess the proof-of-concept and accuracy of self-detection of acute coronary artery occlusion by patients during daily life situations and during the very early stages of acute coronary artery occlusion. Methods: In this multicentre, observational study, we tested the operational feasibility, specificity, and sensitivity of our RELF method, a three-lead detection system with an automatic algorithm built into a mobile handheld device, for detection of acute coronary artery occlusion. Patients were recruited continuously by physician referrals from three Belgian hospitals until the desired sample size was achieved, had been discharged with planned elective percutaneous coronary intervention, and were able to use a smartphone; they were asked to perform random ambulatory self-recordings for at least 1 week. A similar self-recording was made before percutaneous coronary intervention and at 60 s of balloon occlusion. Patients were clinically followed up until 1 month after discharge. We quantitatively assessed the operational feasibility with an automated dichotomous quality check of self-recordings. Performance was assessed by analysing the receiver operator characteristics of the ST difference vector magnitude. This trial is registered with ClinicalTrials.gov, number NCT02983396. Findings: From Nov 18, 2016, to April 25, 2018, we enrolled 64 patients into the study, of whom 59 (92%) were eligible for self-applications. 58 (91%) of 64 (95% CI 81·0–95·6) patients were able to perform ambulatory self-recordings. Of all 5011 self-recordings, 4567 (91%) were automatically classified as successful within 1 min. In 65 balloon occlusions, 63 index tests at 60 s of occlusion in 55 patients were available. The mean specificity of daily life recordings was 0·96 (0·95–0·97). The mean false positive rate during daily life conditions was 4·19% (95% CI 3·29–5·10). The sensitivity for the target conditions was 0·87 (55 of 63; 95% CI 0·77–0·93) for acute coronary artery occlusion, 0·95 (54 of 57; 0·86–0·98) for acute coronary artery occlusion with electrocardiogram (ECG) changes, and 1·00 (35 of 35) for acute coronary artery occlusion with ECG changes and ST-segment elevation myocardial infarction criteria (STEMI). The index test was more sensitive to detect a 60 s balloon occlusion than the STEMI criteria on 12-lead ECG (87% vs 56%; p

A 32-year-old woman with unremarkable medical history presented with hemodynamically stable, regular tachycardia of 150 bpm (Figure 1). Figure 1. ECG: tachycardia. What is the most likely diagnosis? Please turn the page to read the diagnosis. The ECG (Figure 1) shows a QRS complex with extreme axis deviation (+160°) that is usually seen during ventricular arrhythmias (fascicular) with a structurally normal heart. However, a narrow QRS complex (90 ms) suggests a supraventricular tachycardia without aberrancy. Supraventricular tachycardia with an abnormal axis can be caused by underlying heart disease, but a positive QRS in lead aVR and a negative lead I …

Introduction Recent studies have characterized drivers in persistent atrial fibrillation using automated algorithm detection with panoramic endocardial mapping by means of basket catheters. We aimed to identify repetitive atrial activation patterns (RAAPs) during ongoing atrial fibrillation (AF) based upon automated annotation of unipolar electrograms (EGMs) recorded with a high-density regional endocardial contact mapping catheter. Methods In 14 persistent AF patients, high-resolution EGMs were recorded for 30 seconds at sequential PentaRay (Biosense Inc) positions covering the entire biatrial surface. All recordings were reviewed off-line with dedicated software allowing automated annotation of the local activation time of the unipolar fibrillatory EGMs (CARTOFINDER; Biosense Inc). RAAPs were defined as a consistent activation pattern (for ≥3 consecutive beats) of either focal activity with centrifugal spread (RAAPfocal ) or rotational activity across the PentaRay splines spanning the AF cycle length (RAAProtational ). Results A total of 498 PentaRay recordings were analyzed (35.6 ± 7.6 per patient). The number of PentaRay recordings displaying RAAP was 9.8 ± 3.1 per patient (range = 3-15), of which 2.4 ± 2.4 RAAProtational (range = 0-7), and 7.4 ± 4.4 RAAPfocal (range = 1-13). 77% of RAAPs portrayed focal firing. The median number of repetitions per 30 second recording was 11 (range = 3-225) per recording. RAAPs were observed both in the right atrium (RA) (35%) and left atrium (LA) (65%), with the majority being near the left PVs/appendage (35% of all RAAPs) and the superior vena cava/right appendage (23% of all RAAPs). Conclusion High-resolution, sequential endocardial EGM-based mapping allows identification of RAAPs in persistent AF. In our series, focal firing was the most frequently observed pattern.

Objectives This study sought to determine the prevalence of patients with 4 isolated veins at repeat ablation after “CLOSE” -guided pulmonary vein isolation (PVI), a strategy based on delivery of contiguous and optimized radiofrequency lesions. Background The likelihood of finding 4 isolated veins at a repeat ablation for atrial fibrillation (AF) recurrence after a first PVI is low. Methods Patients undergoing repeat ablation for AF recurrence after first CLOSE-guided PVI were included. At repeat: 1) the status of the PV was evaluated; and 2) high-density voltage mapping was performed. In case of pulmonary vein reconnection (PVR), veins were reisolated. In patients with 4 isolated veins, empirical trigger or substrate ablation was performed. Results Of 326 patients undergoing CLOSE-guided PVI for paroxysmal AF, 45 patients underwent repeat ablation for AF recurrence (11 ± 7 months after first PVI). In 28 patients, all veins were still isolated (62%). They showed similar clinical characteristics and similar time from first PVI to AF recurrence (8 ± 7 vs. 6 ± 6 months, respectively, p = 0.453) compared with patients with PVR. In contrast, they were characterized by a higher incidence of low voltage (57% vs. 17%, p = 0.033). Patients with 4 isolated veins, compared with patients treated for PVR, showed a lower 12-month freedom from AF after repeat ablation (61% vs. 88%, p = 0.045). Conclusions After CLOSE-guided ablation, PVR is no longer the rule in patients with AF recurrence. Patients with AF recurrence and 4 isolated veins present with a similar clinical profile and time to recurrence as patients with PVR.

Aims To assess in young athletes (i) the variability in the percentage of abnormal electrocardiograms (ECGs) using different criteria and (ii) the variability in ECG interpretation among cardiologists and sport physicians. Methods and Results Electrocardiograms of 138 athletes were categorized by seven cardiologists according to the original European Society of Cardiology (ESC) criteria by Corrado (C), subsequently modified by Uberoi (U), Marek (M), and the Seattle criteria (S); seven sports physicians only used S criteria. The percentage of abnormal ECGs for each physician was calculated and the percentage of complete agreement was assessed. For cardiologists, the median percentage of abnormal ECGs was 14% [interquartile range (IQR) 12.5–20%] for C, 11% (IQR 9.5–12.5%) for U [not significant (NS) compared with C], 11% (IQR 10–13%) for M (NS compared with C), and 7% (IQR 5–8%) for S ( P < 0.005 compared with C); complete agreement in interpretation was 64.5% for C, 76% for U ( P < 0.05 compared with C), 74% for M (NS compared with C), and 84% for S ( P < 0.0005 compared with C). Sport physicians classified a median of 7% (IQR 7–11%) of ECGs as abnormal by S ( P = NS compared with cardiologists using S); complete agreement was 72% ( P < 0.05 compared with cardiologists using S). Conclusion Seattle criteria reduced the number of abnormal ECGs in athletes and increased agreement in classification. However, variability in ECG interpretation by cardiologists and sport physicians remains high and is a limitation for ECG-based screening programs.

We have recently shown that a contact force (CF)-guided ablation protocol respecting region-specific criteria of lesion contiguity and lesion depth ('CLOSE' protocol) is associated with high incidence of acute durable pulmonary vein (PV) isolation (PVI) and a high single-procedure arrhythmia-free survival at 1 year. In the present study, we compared efficiency, safety, and efficacy of 'CLOSE'-guided PVI to conventional CF-guided PVI (CONV-CF).Fifty consecutive paroxysmal atrial fibrillation (AF) patients underwent PV encircling using a CF-sensing catheter targeting an interlesion distance (ILD) ≤6 mm and ablation index (AI) ≥400 and ≥550 at posterior and anterior wall ('CLOSE' group). Results were compared to the last 50 patients undergoing 'CONV-CF'. All patients underwent adenosine testing after PVI. Arrhythmia recurrence was defined as any atrial tachyarrhythmia (ATA)30 s on Holter at 3, 6, and 12 months. Clinical characteristics did not differ. Contact force variability was comparable in between both groups (proportion of applications with intermittent contact 2% in 'CLOSE' vs. 1% in CONV-CF, P = 0.67). In the 'CLOSE' group, procedure time and radiofrequency (RF) time per circle were shorter (respectively 149 ± 33 min vs. 192 ± 42 min, P 0.0001 and 18 ± 4 min vs 28 ± 7.5 min, P 0.0001) and incidence of adenosine-proof isolation was higher (97% vs. 82%, P 0.001). No complications were observed in the 'CLOSE' group, one tamponade in the 'CONV-CF' group. At 12 months, single-procedure freedom from ATA was 94% in 'CLOSE' vs. 80% in 'CONV-CF' group (P 0.05). In both groups, the majority of reconnections at repeat were associated with either ILD 6 mm and/or AI 400/550 (100% vs. 83%, P = 0.99).'CLOSE'-guided PVI improves procedural and 1 year outcome in CF-guided PVI while shortening procedure time. Improvement cannot be explained by differences in CF variability and is most likely due to the strict application of criteria for contiguity and ablation index. A randomized controlled trial is needed to exclude the possible contribution of a learning curve.

Aims Catheter ablation is indicated in patients with symptomatic paroxysmal atrial fibrillation (AF) resistant to antiar- rhythmic drug therapy (ADT). We investigated whether continued use of previously ineffective ADT beyond the post-ablation blanking period reduces recurrence of atrial tachyarrhythmia within the 1st year after ablation. Methods and results This was a multicentre, randomized controlled study in patients undergoing contact force-guided pulmonary vein isolation (PVI) for paroxysmal AF in whom previously ineffective ADT was continued during a blanking period of 3 months. If free of AF at the end of the blanking period, patients were randomly assigned in the ratio of 1:1 to continue ADT (ADT ON group, n= 77) or discontinue ADT (ADT OFF group, n= 76). Patients were followed up until 1 year after PVI, with clinical visits, Hotter monitoring, and quality-of-life (QOL) questionnaires at 6 and 12 months post-procedure. Analysis of the primary endpoint (any documented atrial tachyarrhythmia lasting >30 s) was performed according to the modified intention-to-treat principle. Secondary endpoints included repeat ablation, unscheduled visits, and QOL score. Baseline clinical characteristics and initial ablation procedure characteristics were comparable between both groups. Three patients were lost to follow-up in each arm. The primary endpoint was observed in 2 of 74 (2.7%) patients in the ADT ON group vs. 16 of 73 (21.9%) patients in the ADT OFF group (P

Background— Pulmonary vein reconnection (PVR) still determines recurrences of atrial fibrillation after contact force (CF)–guided pulmonary vein isolation. We studied whether acute PVR (adenosine and waiting time) and late PVR (at repeat) are explained by incomplete transmurality and contiguity within the deployed radiofrequency circle. Methods and Results— We analyzed 42 CF-guided ipsilateral pulmonary vein isolation procedures. For each radiofrequency tag within the circle, we collected data reflecting lesion depth (time of application, power, impedance drop [Δ-Imp], CF, force–time integral [FTI], and ablation index [AI]) and contiguity (automated interlesion distance [ILD]). Ablation line contiguity index (ALCI) was developed as a novel automated algorithm combining depth and contiguity into one single criterion. Each circle was subdivided into 10 segments. For each segment, we determined its weakest link by annotating time min , power min , Δ-Imp min , CF min , FTI min , AI min , ILD max , and ALCI min . Compared with segments without PVR (n=758), PVR segments (n=44) were characterized by lower Δ-Imp min (4.8 versus 7.4 Ω), CF min (8.5 versus 11.8 g), FTI min (351 versus 473 gs), AI min (367 versus 408 arbitrary unit [au]), and higher ILD max (6.8 versus 5.5 mm). ALCI min was significantly lower in segments with PVR (74% versus 104%; P Conclusions— In CF-guided pulmonary vein isolation, PVR is explained by lack of both lesion depth and contiguity within the deployed radiofrequency circle. ALCI, a novel measure combining contiguity and depth, is the most accurate predictor for durable segments. By avoiding weak links in the ablation chain, ALCI-guided ablation is expected to improve success rate of point-by-point radiofrequency ablation.

Purpose. We aimed to study long-term outcome after pulmonary vein isolation (PVI) guided by remote magnetic navigation (RMN) and provided comparative data to outcome after manual navigation (MAN). Methods. Three hundred thirty-six patients with symptomatic paroxysmal AF underwent PVI by irrigated point-by-point radiofrequency (RF) ablation (RMN, n=114 versus MAN, n=222). Patients were followed up with symptom guided rhythm monitoring for a period up to 43 months. The end point of the study was freedom from repeat ablation after a single procedure and without antiarrhythmic drug treatment (ADT). Results. At the end of follow-up (median 26.3 months), freedom from repeat ablation was comparable between RMN and MAN (70.9% versus 69.5%, p=0.61). At repeat, mean number of reconnected veins was 2.4 ± 1.2 in RMN versus 2.6 ± 1.0 in MAN (p=0.08). The majority of repeat procedures occurred during the first year (82.1% in RMN versus 78.5% in MAN; p=0.74). Conclusion. On the long term (up to 3 years) and in a large cohort of patients with paroxysmal AF, RMN-guided PVI is as effective as MAN guided PVI. In both strategies the majority of repeat procedures occurred during the first year after index procedure.

Aims Prior reports using pacing manoeuvres, demonstrated an up to 42% prevalence of residual pulmonary vein to left atrium (PV–LA) exit conduction after apparent LA–PV entry block. We aimed to determine in a two-centre study the prevalence of residual PV–LA exit conduction in the presence of unambiguously proven entry block and without pacing manoeuvres. Methods and results Of 378 patients, 132 (35%) exhibited spontaneous pulmonary vein (PV) potentials following circumferential PV isolation guided by three-dimensional mapping and a circular mapping catheter. Pulmonary vein automaticity was regarded as unambiguous proof of LA–PV entry block. We determined the prevalence of spontaneous exit conduction of the spontaneous PV potentials toward the LA. Pulmonary vein automaticity was observed in 171 PVs: 61 right superior PV, 33 right inferior PV, 47 left superior PV, and 30 left inferior PV. Cycle length of the PV automaticity was >1000 ms in all cases. Spontaneous PV–LA exit conduction was observed in one of 171 PVs (0.6%). In a subset of 69 PVs, pacing from within the PV invariably confirmed PVLA exit block. Conclusion Unidirectional block at the LA–PV junction is unusual (0.6%). This observation is supportive of LA–PV entry block as a sufficient electrophysiological endpoint for PV isolation.

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5][![Graphic][6] ][6] A 21-year-old man with neurofibromatosis type 1 neglected follow-up during a decade and presented with progressive exertional dyspnea and thoracic tightness. Echocardiography

A Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society (HRS/EHRA/APHRS) expert consensus statement on the diagnosis and management of Brugada Syndrome was published in 2013. Since then new intriguing observations have been made that are summarised in this editorial with a special focus on the underlying mechanism, genetics, provocative testing, risk stratification and therapeutic options.

We describe a 74-year-old man presenting with a life-threatening left-sided haemothorax as a result of an implantable cardioverter defibrillator lead perforation occurring 1 month after implantation.

Pacemaker lead infection is a rare condition, most often occurring when intervention is needed after pacemaker implantation. Diagnosis is by blood cultures and confirmation by transoesophageal echocardiography; transthoracic echocardiography is often inadequate. A literature review indicated the microorganism most responsible for late lead infection is Staphylococcus epidermidis (which can grow on plastic material). A retrospective analysis of patient files from the authors' institution (1993-97) yielded three patients with proven pacemaker lead endocarditis. The diagnosis of pacemaker endocarditis was by transoesophageal echocardiography. The endocarditis appeared after a long period and in two of the three patients there was S epidermidis infection. Thoracotomy with removal of the infected system was performed because of the large dimensions of the vegetations. A new pacemaker was implanted: in one patient with endocardial leads, in the other two with epicardial leads. All three patients recovered well and follow up was uneventful for at least one year. Keywords: endocarditis; pacemaker lead infection; staphylococci; transoesophageal echocardiography

A 62-year-old patient was referred for the treatment of highly symptomatic and drug-resistant paroxysmal atrial fibrillation (AF). First AF paroxysm occurred as early as 1992. At that time, patient was diagnosed with a partial anomalous pulmonary venous connection (PAPVC) without atrial septal defect (ASD). Now repetitive Holter monitoring revealed paroxysms of sustained AF. Transthoracic echocardiogram showed a right ventricular end-diastolic diameter of 44 mm, a systolic pulmonary arterial pressure of 52 mmHg, and a shunt ratio of 2.13. Left atrial (LA) diameter (PS-LAX) was 41 mm. Right atrium (RA) was dilated with a surface area of 24 cm2. Surgical repair of the anomalous pulmonary veins (PVs) …