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In 10% of ischemic strokes, non-valvular atrial fibrillation (NVAF) is detected retroactively. Milder, or even asymptomatic forms of NVAF have shown high mortality, thrombotic risk, and deterioration of cognitive function. The current guidelines for the diagnosis and treatment of AF contain "grey areas", such as the one related to anticoagulant treatment in men with CHA2DS2-VASc score 1 and women with score 2. Moreover, parameters such as renal function, patient weight or left atrium remodelling are missing from the recommended guidelines scores. Vulnerable categories of patients including the elderly population, high hemorrhagic risk patients or patients with newly diagnosed paroxysmal episodes of atrial high rate at device interrogation are at risk of underestimation of the thrombotic risk. This review presents a systematic exposure of the most important gaps in evaluation of thrombotic and hemorrhagic risk in patients with NVAF. The authors propose new algorithms and risk factors that should be taken into consideration for an accurate thrombotic and hemorrhagic risk estimation, especially in vulnerable categories of patients. [ABSTRACT FROM AUTHOR]

Background: Remote monitoring (RM) is becoming a standard of care for patients with cardiac resynchronization therapy (CRT). This technology combines the use of pacemakers or implantable cardioverterdefibrillators (ICD) and wireless communication to provide physicians with continuous, real-time information on the patient's cardiac activity. The purpose of the study was to evaluate if the remote monitoring technology in the follow-up CRT patients is feasible and safe. Methods: A total of nine patients were enrolled in the study, implanted with a CRT system with wireless transmission capabilities. Immediately after the procedure received the RM, were enrolled in the virtual clinic and instructed by the doctor how to use the device at home. Regular virtual transmissions were made automatically every 3 weeks, respecting optimal transmission conditions. The accumulation of fluid in the lungs, atrial or ventricular tachyarrhythmia together with system integrity automatically activate alerts. Results: One hundred and one transmissions were collected and analyzed from the virtual ward. Average follow-up was 7.7±4.8 months, longest follow-up was 18 months. None of the patients experienced complications during the study period, with three of them being follow-up solely through telemetric means by implanting physician. Treatment optimization was successfully conducted via phone consultations, when necessary, without any adverse events. Conclusions: The results of our study suggest that RM could be integrated into routine CRT management protocols, enhancing patients care and resource utilization. [ABSTRACT FROM AUTHOR]

Right ventricular pacing is has deletorius effects due to left ventricular dysynchrony and remodelling and may result in heart failure. Over the last decade, His bundle pacing has emerged as the most physiologic form pacing. However, it has limitations, such as higher capture thresholds, lower R wave amplitudes, atrial oversensing, and increased risk for lead revisions from late threshold increase with subsequent premature battery depletion, which has prevented a wider adoption of this technique in routine clinical practice. Left bundle branch pacing has been developed as an alternative physiologic pacing strategy that overcomes most of His bundle pacing limitations. This article summarizes the current status of left bundle branch pacing. [ABSTRACT FROM AUTHOR]

Introduction - The current scientific literature suggests similar or even better catheter contact on caval regions of the cavo-tricuspid isthmus (CTI) compared to the more medial or annular part. Yet CTI ablation can be challenging owing to instability at the inferior vena cava (IVC) edge. No study specifically addressed the issue of catheter-tissue contact on caval/mid/annular regions of the CTI. Methods - Twenty-seven patients (22 men, 67±12 years) underwent typical atrial flutter ablation with a contact force (CF) sensing catheter (Tacticath 75, Abott) and were prospectively included. Operators aimed at optimizing CF for all RF pulses. The product of CF, time (force-time integral; FTI) and delivered power (FTPI) has been proposed as an estimate of lesion size. In a subset of 8 consecutive pts, electrograms (EGM) of all RF lesions were analyzed. Annular CTI was defined as sites showing both atrial and ventricular near-field bipolar EGM. Mid CTI sites had only atrial near field bipolar EGM on both distal and proximal dipoles (or distal only in case of superior-to-inferior approach). Caval sites had near-field bipolar EGM only in distal dipole, while the proximal one was inferiorly located. Results - Complete persistent (at 30 min) CTI block was obtained in all patients. A steerable sheath was used in 12 pts (44%). Procedure duration was 93±30 min, RF delivery time 10±6 min, fluoroscopy time 14±8 min. Mean CF was 15.8±5.9 g. CF was signifi- cantly lower (11.1±9.7 g) at the caval CTI than at mid CTI (19.9±11.8 g) and annular CTI (20±12.2 g; p=0.001). CF and FTI were higher during sinus rhythm than during Fl(23.2±15.3 vs 18.5±15.4 g, p=0.04 and 677±432 vs 532±357 gs, p=0.03). Use of a sheath improved mean CF (24.4±12.5 vs 18.4±14.9 g, p=0.01) but this was not significant at caval sites (17.5±11.4 vs 12.6±10.7 g, p=0.31). Conclusion - Applied forces are significantly lower at the IVC edge during CTI ablation. This supports the use of a steerable sheath in challenging cases. [ABSTRACT FROM AUTHOR]

Objective: To assess the frequency and types of genetic mutations in patients with arrhythmias who underwent cardiac device implantation. Methods: Retrospective observational study, including 38 patients with different arrhythmias and cardiac arrest as a first cardiac event. Treatment modalities encompass pacemakers, transvenous defibrillators, loop recorders, subcutaneous defibrillators, and cardiac resynchronization therapy. All patients underwent genetic testing, using commercially available panels (106-174 genes). Outcome measures include mortality, arrhythmia recurrence, and device-related complications. Results: Clinical parameters revealed a family history of sudden cardiac death in 19 patients (50%), who were predominantly male (58%) and had a mean age of 44.5 years and a mean left ventricle ejection fraction of 40.3%. Genetic testing identified mutations in various genes, predominantly TMEM43 (11%). In two patients (3%) with arrhythmogenic cardiomyopathy, complete subcutaneous defibrillator extraction with de novo transvenous implantable cardioverter-defibrillator implantation was needed. The absence of multiple associations among severe gene mutations was crucial for cardiac resynchronization therapy response. Mortality in this group was around 3% in titin dilated cardiomyopathy patients. Conclusions: Integration of genetic testing into the decision-making process for patients with electronic devices represents a paradigm shift in personalized medicine. By identifying genetic markers associated with arrhythmia susceptibility, heart failure etiology, and cardiac resynchronization therapy response, clinicians can tailor device choices to optimize patient outcomes.

In 10% of ischemic strokes, non-valvular atrial fibrillation (NVAF) is detected retroactively. Milder, or even asymptomatic forms of NVAF have shown high mortality, thrombotic risk, and deterioration of cognitive function. The current guidelines for the diagnosis and treatment of AF contain "grey areas", such as the one related to anticoagulant treatment in men with CHA2DS2-VASc score 1 and women with score 2. Moreover, parameters such as renal function, patient weight or left atrium remodelling are missing from the recommended guidelines scores. Vulnerable categories of patients including the elderly population, high hemorrhagic risk patients or patients with newly diagnosed paroxysmal episodes of atrial high rate at device interrogation are at risk of underestimation of the thrombotic risk. This review presents a systematic exposure of the most important gaps in evaluation of thrombotic and hemorrhagic risk in patients with NVAF. The authors propose new algorithms and risk factors that should be taken into consideration for an accurate thrombotic and hemorrhagic risk estimation, especially in vulnerable categories of patients., Competing Interests: The authors report no conflicts of interest in this work., (© 2023 Rachieru et al.)

Aim: The aim of our study was to retrospectively evaluate known factors such as CHA2DS2-VASc, but, also, new factors (such as left atrial remodeling), associated with the development of stroke in patients with atrial fibrillation (AFi)., Material and Methods: We performed a retrospective study in which 251 patients with AFi were included. 47 patients had an ischemic stroke before the diagnosis of AFi, at the time of diagnosis or after AFi was diagnosed. The CHA2DS2-VASc score was analyzed for all patients together with other left atrial remodeling parameters., Results: We observed that among the patients with ischemic stroke approximately 61.70% were over 72.5 years old compared to those without stroke who presented this age in a proportion of only 44.61% (OR=2.001, P=0.0367). The CHA2DS2-VASc score had the greatest statistical impact for stroke, as expected. Patients with a CHA2DS2-VASc score >4.5 presented stroke in a proportion of 87.23% compared to CHA2DS2-VASc <4.5 who had stroke only in a proportion of 12.77% (OR=11.51, P=<0.0001). Regarding left atrial remodeling parameters, low LA ejection fraction was associated with a high percentage of stroke among patients (61.70%) compared to those with LA EF>34.5% who had stroke only in a percentage of 38.30% (OR= 2.124, P=0.0238)., Conclusions: Although the CHA2DS2-VASc score remains a good factor for predicting the association of AFi with ischemic stroke, echocardiographic parameters for the evaluation of the left atrium can be used as new risk factors for predicting the occurrence of ischemic stroke in patients with AFi., Competing Interests: None to declare., (Copyright © 2023, Medical University Publishing House Craiova.)

Background: It has been shown that a new tissue Doppler index, E/(E'×S'), including the ratio between early diastolic transmitral and mitral annular velocity (E/E'), and the systolic mitral annular velocity (S'), has a good accuracy to predict left ventricular filling pressure., Objectives: We investigated the value of E/(E'×S') to predict cardiac death in patients with heart failure., Methods: Echocardiography was performed in 339 consecutive hospitalized patients with heart failure, in sinus rhythm, after appropriate medical treatment, at discharge and after one month. Worsening of E/(E'×S') was defined as any increase of baseline value. The end point was cardiac death., Results: During the follow-up period (35.2 ± 8.8 months), cardiac death occurred in 51 patients (15%). The optimal cut-off value for the initial E/(E'×S') to predict cardiac death was 2.83 (76% sensitivity, 85% specificity). At discharge, 252 patients (74.3%) presented E/(E'×S') ≤ 2.83 (group I) and 87 (25.7%) presented E/(E'×S') > 2.83 (group II), respectively. Cardiac death was significantly higher in group II than in group I (38 deaths, 43.7% vs 13 deaths, 5.15%, p < 0.001). By multivariate Cox regression analysis, including variables that affected outcome in univariate analysis, E/(E'×S') at discharge was the best independent predictor of cardiac death (hazard ratio = 3.09, 95% confidence interval = 1.81-5.31, p = 0.001). Patients with E/(E'×S') > 2.83 at discharge and its worsening after one month presented the worst prognosis (all p < 0.05)., Conclusions: In patients with heart failure, the E/(E'×S') ratio is a powerful predictor of cardiac death, particularly if it is associated with its worsening.

Background: Onset of atrial fibrillation (AF) in patients with heart failure (HF) is usually associated with a high occurrence of cardiovascular complications. E/(E'×S') ratio (E=early diastolic transmitral velocity, E'=early mitral annular diastolic velocity and S'=systolic mitral annulus velocity) has been shown to reflect left ventricular filling pressure., Objective: We investigate whether E/(E'×S') could be a predictor of new-onset AF in patients with HF., Methods: We analyzed 113 consecutive hospitalized patients with HF, in sinus rhythm, after appropriate medical treatment. Patients with histories of AF, inadequate echocardiographic images, congenital heart disease, paced rhythm, significant primary valvular disease, acute coronary syndrome, coronary revascularization during follow-up, severe pulmonary disease or renal failure were not included. E/(E'×S') was determined using the average of septal and lateral mitral annular velocities. The primary study end-point was the new-onset AF., Results: During the follow-up period (35.7±11.2 months), 33 patients (29.2%) developed AF. Mean E/(E'×S') was 3.09±1.12 in these patients, while it was 1.72±1.34 in the other patients (p<0.001). The optimal E/(E'×S') cut-off to predict new-onset AF was 2.2 (88% sensitivity, 77% specificity). There were 64 patients (56.6%) with E/(E'×S')<2.2 and 49 (43.4%) with E/(E'×S')>2.2. New-onset AF was higher in patients with E/(E'×S')>2.2 than in patients with E/(E'×S')<2.2 [29 (59.1%) versus 4 (6.2%), p<0.001]. On multivariate Cox analysis including the variables that predicted AF on univariate analysis, E/(E'×S') was the only independent predictor of new-onset AF (hazard ratio=2.26, 95% confidence interval=1.25-4.09, p=0.007)., Conclusion: In patients with HF, E/(E'×S') seems to be a good predictor of new-onset AF.