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Atrial fibrillation (AF) is one of the most prevalent cardiac arrhythmias in the world. Patients with AF also suffer from heart failure (HF). The relationship between AF and HF is often considered bidirectional and both share very similar risk factors. The mechanism of AF-induced cardiomyopathy lies in 3 distinct components: tachycardia-related cardiac dysfunction, heart rhythm irregularity, and AF-induced atrial myopathy. These components are mediated by calcium mishandling, neurohormonal activation, oxidative stress, myocardial supply-demand mismatch, and irreversible fibrosis and remodeling. Managing AF-induced cardiomyopathy should focus on early rhythm control to mitigate the development of irreversible remodeling and atrial myopathy., Competing Interests: Disclosure Dr L. Di Biase is a consultant for Biosense Webster, Stereoataxis and Rhythm Management, and has received speaker honoraria/travel from Biosense Webster, St. Jude Medical (now Abbott), Boston Scientific, Medtronic, Biotronik, Atricure, Baylis, and Zoll. The other authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Aims: Studies have shown correlations between early recurrence (ER) and late recurrence (LR) of atrial arrhythmia after ablation with thermal technologies. This admIRE trial (NCT05293639) subanalysis aims to analyse ER vs. LR in patients with paroxysmal atrial fibrillation (PAF) undergoing pulsed field ablation (PFA)., Methods and Results: Patients with symptomatic paroxysmal atrial fibrillation and ≥1 transtelephonic monitoring transmission during the blanking period were included (n = 169). ER was defined as documented recurrence in the blanking period (days 1-90), and LR as recurrence in the evaluation period (days 91-365). Freedom from 12-month recurrence was estimated using Kaplan-Meier method. A Cox proportional-hazards regression model, with ER as the primary factor, and adjusted for age, sex, and body mass index, was used to estimate hazard ratios (HRs) and 95% CI. ER was observed in 20.1% (31/169) of patients (66.1 ± 7.1 years, 35.5% female, 46.6 ± 48.4-month PAF history). Time to first documented ER was 49 (37-61) days. Occurrence of LR was 16.7% (23/138) in patients without ER, 71.0% (22/31) in those with ER, and 87.0% (20/23) in patients whose ER onset occurred within the first 2 months. Twelve-month freedom from documented recurrence was significantly lower in patients with ER at 29.0% (95% CI, 13.1-45.0%) vs. 82.5% (95% CI, 75.9-89.1%) in those without ER (adjusted HR, 7.9; 95% CI, 4.1-15.1; P < 0.001)., Conclusion: This admIRE subanalysis demonstrated that PAF patients who experience ER after PFA are at a substantially higher risk for LR. The optimal duration of the blanking period post-PFA needs further assessments., Clinicaltrials.gov Identifier: NCT05293639., Competing Interests: Conflict of interest: L.D.B. has served as a consultant for Biosense Webster, Inc., Stereotaxis, I-Rhythm Abbott, Boston Scientific, Medtronic, Biotronik, AtriCure, Siemens, Haemodinamics and Zoll Medical. V.Y.R. reports receiving consulting fees and grant support from BiosenseWebster; unrelated to this article, serves as a consultant for and has equity in Ablacon, Acutus Medical, Affera-Medtronic, Anumana, Apama Medical-Boston Scientific, APN Health, Append Medical, Aquaheart, Atacor, Autonomix, Axon Therapies, Backbeat, BioSig, CardiaCare, Cardiofocus, CardioNXT/AFTx, Circa Scientific, CoRISMA, Corvia Medical, Dinova-Hangzhou DiNovA EP Technology, East End Medical, EPD-Philips, EP Frontiers, Epix Therapeutics-Medtronic, EpiEP, Eximo, Farapulse-Boston Scientific, Field Medical, Focused Therapeutics, HRT, Intershunt, Javelin, Kardium, Keystone Heart, Laminar Medical, LuxMed, Medlumics, Middlepeak, Neutrace, Nuvera-Biosense Webster, Oracle Health, Pulse Biosciences, Restore Medical, Sirona Medical, SoundCath, Valcare, Volta Medical; and unrelated to this work, he has served as a consultant for Abbott, Adagio Medical, AtriAN, BioTel Heart, Biotronik, Boston Scientific, Cairdac, Cardionomic, CoreMap, Fire1, Gore & Associates, Impulse Dynamics, Medtronic, Novartis, Novo Nordisk, Philips; and unrelated to this work, he has equity in Atraverse, DRS Vascular, Manual Surgical Sciences, Newpace, Nyra Medical, Soundcath, Surecor, and Vizaramed. D.N. has received consulting fees from Biosense Webster, Inc. and AtriCure. W.H.S. has received grants from Biosense Webster, Inc. and Medtronic; and has received consulting fees from Boston Scientific, Biosense Webster, Inc., and Abbott. S.G. receives consulting fees from Biosense Webster, Inc., and Medtronic. V.I. receives consulting fees from Biosense Webster, Inc. D.N. has served as a consultant for and received research grants from Abbott, Boston Scientific, Medtronic, Biosense Webster, Inc., and Adagio; and has received research grants form Laminar Pharma. J.O. has served as a consultant for Biosense Webster, Inc., Boston Scientific, and Volta; has received speaker honoraria from Abbott, Boston Scientific, and Biosense Webster, Inc.; and has received grant support from Biosense Webster, Inc., and Boston Scientific. M.M. reports grants from Biosense Webster, Inc., and Boston Scientific; consulting fees from Biosense Webster, Inc, Boston Scientific, Philips, and Medtronic; support for attending meetings/travel from Biosense Webster, Inc, and Boston Scientific; and stock/stock options from NewPace Limited and EPD Solutions. H.C. receives consulting fees from Biosense Webster, Inc., and Boston Scientific and payment for honoraria from Boston Scientific and Medtronic. O.W. serves as a consultant for Biosense Webster, Inc. A.N. serves as a consultant for Abbott, Biosense Webster, Inc., Biotronik, Boston Scientific, and iRhythm. M.B. and C.F.L. have nothing to disclose., (© The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: After a cryptogenic stroke, patients often will require prolonged cardiac monitoring; however, the subset of patients who would benefit from long-term rhythm monitoring is not clearly defined., Objective: The purpose of this study was to create a risk score by identifying significant predictors of atrial fibrillation (AF) using age, sex, comorbidities, baseline 12-lead electrocardiogram, short-term rhythm monitoring, and echocardiographic data and to compare it to previously published risk scores., Methods: Patients admitted to Montefiore Medical Center between May 2017 and June 2022 with a primary diagnosis of cryptogenic stroke or transient ischemic attack who underwent long-term rhythm monitoring with an implantable cardiac monitor were retrospectively analyzed., Results: Variables positively associated with a diagnosis of clinically significant AF include age (P <.001), race (P = .022), diabetes status (P = .026), chronic obstructive pulmonary disease status (P = .012), presence of atrial runs (P = .003), number of atrial runs per 24 hours (P <.001), total number of atrial run beats per 24 hours (P <.001), number of beats in the longest atrial run (P <.001), left atrial enlargement (P = .007), and at least mild mitral regurgitation (P = .009). We created a risk stratification score for our population, termed the ACL score. The ACL score demonstrated superiority to the CHA 2 DS 2 -VASc score and comparability to the C 2 HEST score for predicting device-detected AF., Conclusion: The ACL score enables clinicians to better predict which patients are more likely to be diagnosed with device-detected AF after a cryptogenic stroke., Competing Interests: Disclosures Dr Di Biase is a consultant for Biosense Webster, Boston Scientific, Stereotaxis, and St. Jude Medical; and has received speaker honoraria from Medtronic, AtriCure, EPiEP, and Biotronik. The other authors have no conflicts of interest to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Atrial fibrillation is the most prevalent cardiac arrhythmia, and catheter ablation (CA) has emerged as a viable treatment option for selected patients. However, its safety profile in liver cirrhosis (LC) populations remains underexplored., Methods: This was an observational analysis of the National Inpatient Sample Database 2016-2020; we analyzed adult encounters undergoing CA for atrial fibrillation who had a concomitant diagnosis of LC. Using propensity scores, encounters were divided into two cohorts based on the presence or absence of LC and matched in a 1:1 fashion using LC as the dependent variable. In-hospital mortality and postprocedure total complications were compared using regression models., Results: 93 830 procedures were identified for non-LC patients and 960 involving LC patients; after propensity score matching, each cohort included 910 hospitalizations. The mean age in the LC-matched cohort was 66.5 ± 9.1 years. In-hospital mortality did not differ between the groups (aOR = 1.01; 95% CI [0.06-16.1]; p = .99). However, the LC cohort exhibited higher odds of total complications (aOR = 1.98; 95% CI [1.42-2.75]; p < .001). Length of stay (LOS) was comparable, but total costs were higher in the LC cohort: LOS was 2 days (95% CI [1-3]) in the LC group versus 3 days (95% CI [1-4]) (p < .11) and LC: $202,000 (95% CI [$142 000-$261 000]) versus non-LC: $189 000, (95% CI [$153 000-$222 000]) (p < .0001)., Conclusion: In this national analysis of patients undergoing CA for AF, those with LC had similar in-hospital mortality, postprocedure complications, and LOS compared to noncirrhotic patients. Furthermore, longitudinal studies are needed to assess the safety profile of CA in this subpopulation., (© 2024 Wiley Periodicals LLC.)

Atrial and ventricular arrhythmias are common in patients with Infiltrative heart diseases. This review discusses ablative techniques for arrhythmias in amyloidosis, sarcoidosis, hemochromatosis, and glycogen storage disorders, primarily focusing on atrial fibrillation (AF). A thorough literature review was conducted on the MEDLINE database to synthesize current knowledge and propose future research directions. AF is the most common arrhythmia identified in patients with amyloidosis due to cellular infiltration and atrial dilation. While catheter ablation is associated with a significantly lower rate of all-cause mortality and admission rate, conflicting data exist regarding the higher risk of pericardial effusion, in-hospital mortality, length of stay, and cost of hospitalization. Cardiac sarcoid predisposes AF due to granulomas, atrial dilation, and scarring. Studies demonstrate encouraging outcomes and low recurrence rates in these patients who undergo ablation for AF, with no difference in complications compared to those without sarcoidosis. AF is the most common arrhythmia in hereditary hemochromatosis (HH), secondary to increased myocardial iron stores and elevated oxidative stress, and is primarily managed by chelation. Scant reports regarding ablation are described for HH and glycogen storage disorders. Catheter ablation is a safe and effective modality for the treatment of AF in infiltrative cardiomyopathy. Future large-scale trials are needed to confirm these findings., (© 2024 Wiley Periodicals LLC.)

The role of antithrombotic therapy in the prevention of ischemic stroke after non-cardiac surgery is unclear. In this study, we tested the hypothesis that the association of new-onset postoperative atrial fibrillation (POAF) on ischemic stroke can be mitigated by postoperative oral anticoagulation therapy. Of 251,837 adult patients (155,111 female (61.6%) and 96,726 male (38.4%)) who underwent non-cardiac surgical procedures at two sites, POAF was detected in 4,538 (1.8%) patients. The occurrence of POAF was associated with increased 1-year ischemic stroke risk (3.6% versus 2.3%; adjusted risk ratio (RRadj) = 1.60 (95% confidence interval (CI): 1.37-1.87), P < 0.001). In patients with POAF, the risk of developing stroke attributable to POAF was 1.81 (95% CI: 1.44-2.28; P < 0.001) without oral anticoagulation, whereas, in patients treated with anticoagulation, no significant association was observed between POAF and stroke (RRadj = 1.04 (95% CI: 0.71-1.51), P = 0.847, P for interaction = 0.013). Furthermore, we derived and validated a computational model for the prediction of POAF after non-cardiac surgery based on demographics, comorbidities and procedural risk. These findings suggest that POAF is predictable and associated with an increased risk of postoperative ischemic stroke in patients who do not receive postoperative anticoagulation., Competing Interests: Competing interests M.E. receives funding from the National Institutes of Health (NIH) (R01AG065554 and R01HL132887) that does not pertain to this manuscript. He holds two patents for acyclic curcubiturils for reversal of drugs of abuse and neuromuscular blocking agents (patent numbers 9956229 and 9469648). He is a member of the associated editorial board for the British Journal of Anaesthesia. D.L.B. discloses the following relationships. Advisory Board: Angiowave, Bayer, Boehringer Ingelheim, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, High Enroll, Janssen, Level Ex, McKinsey, Medscape Cardiology, Merck, MyoKardia, NirvaMed, Novo Nordisk, PhaseBio, PLx Pharma and Stasys; Board of Directors: American Heart Association New York City, Angiowave (stock options), Bristol Myers Squibb (stock), DRS.LINQ (stock options) and High Enroll (stock); Consultant: Broadview Ventures, Hims, SFJ and Youngene; Data Monitoring Committee: Acesion Pharma, Assistance Publique-Hôpitaux de Paris, Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Boston Scientific (chair, PEITHO trial), Cleveland Clinic, Contego Medical (chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo; for the ABILITY-DM trial, funded by Concept Medical; for ALLAY-HF, funded by Alleviant Medical), Novartis, Population Health Research Institute and Rutgers University (for the NIH-funded MINT Trial); Honoraria: American College of Cardiology (ACC) (senior associate editor, Clinical Trials and News; chair, ACC Accreditation Oversight Committee), Arnold and Porter law firm (work related to Sanofi/Bristol Myers Squibb clopidogrel litigation), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee, funded by Boehringer Ingelheim; AEGIS-II executive committee, funded by CSL Behring), Belvoir Publications (editor in chief, Harvard Heart Letter), Canadian Medical and Surgical Knowledge Translation Research Group (clinical trial steering committees), CSL Behring (American Heart Association lecture), Cowen and Company, Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (editor in chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (guest editor and associate editor), K2P (co-chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Oakstone CME (course director, Comprehensive Review of Interventional Cardiology), Piper Sandler, Population Health Research Institute (for the COMPASS operations committee, publications committee and steering committee and USA national co-leader, funded by Bayer), WebMD (CME steering committees) and Wiley (steering committee); Other: Clinical Cardiology (deputy editor); Patent: sotagliflozin (named on a patent for sotagliflozin assigned to Brigham and Women's Hospital, assigned to Lexicon; neither D.L.B. nor Brigham and Women's Hospital receive any income from this patent); Research Funding: Abbott, Acesion Pharma, Afimmune, Aker Biomarine, Alnylam, Amarin, Amgen, AstraZeneca, Bayer, Beren, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Cardax, CellProthera, Cereno Scientific, Chiesi, CinCor, Cleerly, CSL Behring, Eisai, Ethicon, Faraday Pharmaceuticals, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Garmin, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Javelin, Lexicon, Eli Lilly, Medtronic, Merck, Moderna, MyoKardia, NirvaMed, Novartis, Novo Nordisk, Otsuka, Owkin, Pfizer, PhaseBio, PLx Pharma, Recardio, Regeneron, Reid Hoffman Foundation, Roche, Sanofi, Stasys, Synaptic, The Medicines Company, Youngene and 89Bio; Royalties: Elsevier (editor, Braunwald’s Heart Disease); Site Co-Investigator: Abbott, Biotronik, Boston Scientific, CSI, Endotronix, St. Jude Medical (now Abbott), Philips, SpectraWAVE, Svelte and Vascular Solutions; Trustee: ACC; Unfunded Research: FlowCo. M.S.S. received funding for investigator-initiated studies from Merck & Co., which does not pertain to this manuscript. He is an associate editor for BMC Anesthesiology. He received honoraria for lectures from Fisher & Paykel Healthcare and Mindray Medical International Limited. He received an unrestricted philanthropic grant from Jeff and Judy Buzen. All other authors have no support from any organization for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work and no other relationships or activities that could appear to have influenced the submitted work., (© 2024. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Background: Evidence from clinical trials of early pulsed field ablation (PFA) systems in treating atrial fibrillation has demonstrated their promising potential to reduce complications associated with conventional thermal modalities while maintaining efficacy. However, the lack of a fully integrated mapping system, a staple technology of most modern electrophysiology procedures, poses limitations in lesion creation and workflow options. A novel variable-loop PFA catheter integrated with an electroanatomic mapping system has been developed that allows for real-time nonfluoroscopic procedural guidance and lesion indexing as well as feedback of tissue-to-catheter proximity. AdmIRE (Assessment of Safety and Effectiveness in Treatment Management of Atrial Fibrillation With the Bosense-Webster Irreversible Electroporation Ablation System), a multicenter, single-arm, Food and Drug Administration investigational device exemption study, evaluated the long-term safety and effectiveness of this integrated PFA system in a large United States-based drug-refractory symptomatic paroxysmal atrial fibrillation patient population., Methods: Using the PFA catheter with a compatible electroanatomic mapping system, patients with drug-refractory symptomatic paroxysmal atrial fibrillation underwent pulmonary vein isolation. The primary safety end point was primary adverse event within 7 days of ablation. The primary effectiveness end point was a composite end point that included 12-month freedom from documented atrial tachyarrhythmia (ie, atrial fibrillation, atrial tachycardia, atrial flutter) episodes, failure to achieve pulmonary vein isolation, use of a nonstudy catheter for pulmonary vein isolation, repeat procedure (except for one redo during blanking), taking a new or previously failed class I or III antiarrhythmic drug at higher dose after blanking, or direct current cardioversion after blanking., Results: At 30 centers, 277 patients with paroxysmal atrial fibrillation (61.5±10.3 years of age; 64.3% male) in the pivotal cohort underwent PFA. More than 25% of the procedures were performed without fluoroscopy. Median (Q1, Q3) pulmonary vein isolation procedure, fluoroscopy, and transpired PFA application times were 81.0 (61.0, 112.0), 7.1 (0.00, 14.3), and 31.0 (24.8, 40.9) minutes, respectively. The primary adverse event rate was 2.9% (8 of 272), with the most common complication being pericardial tamponade. The 12-month primary effectiveness end point was 74.6%. The 1-year freedom from atrial fibrillation, atrial tachycardia, or atrial flutter recurrence rate after blanking was 75.4%. Substantial improvements in quality of life were observed as early as 3 months after the procedure, concurrent with a reduction in multiple health care use measures., Conclusions: AdmIRE confirmed the safety and effectiveness of the variable-loop PFA catheter, with short procedure and PFA application times and low fluoroscopy exposure., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05293639., Competing Interests: Dr Reddy reports receiving consulting fees and grant support from Biosense-Webster; unrelated to this article, serves as a consultant for and has equity in Ablacon, Acutus Medical, Affera-Medtronic, Anumana, Apama Medical-Boston Scientific, APN Health, Aquaheart, Atacor, Autonomix, Axon Therapies, Backbeat, BioSig, CardiaCare, Cardiofocus, CardioNXT/AFTx, Circa Scientific, CoRISMA, Corvia Medical, Dinova-Hangzhou DiNovA EP Technology, East End Medical, EPD-Philips, EP Frontiers, Epix Therapeutics-Medtronic, EpiEP, Eximo, Farapulse-Boston Scientific, Field Medical, Focused Therapeutics, HRT, Intershunt, Javelin, Kardium, Keystone Heart, Laminar Medical, LuxMed, Medlumics, Middlepeak, Neutrace, Nuvera-Biosense Webster, Oracle Health, Restore Medical, Sirona Medical, SoundCath, and Valcare; unrelated to this work, has served as a consultant for Abbott, Adagio Medical, Append Medical, AtriAN, BioTel Heart, Biotronik, Boston Scientific, Cairdac, Cardionomic, CoreMap, Fire1, Gore & Associates, Impulse Dynamics, Medtronic, Novartis, Novo Nordisk, Philips, and Pulse Biosciences; and unrelated to this work, has equity in Atraverse, DRS Vascular, Manual Surgical Sciences, Newpace, Nyra Medical, Soundcath, Surecor, and Vizaramed. Dr Calkins receives consulting fees from Biosense Webster and Boston Scientific and payment for honoraria from Boston Scientific and Medtronic. Dr Mansour reports grants from Biosense Webster, Inc, and Boston Scientific; consulting fees from Biosense Webster, Inc, Boston Scientific, Philips, and Medtronic; support for attending meetings/travel from Biosense Webster, Inc, and Boston Scientific; and stock/stock options from NewPace Limited and EPD Solutions. Dr Wazni serves as a consultant for Biosense Webster. Dr Di Biase is a consultant for Biosense Webster, Stereoataxis, and Rhythm Management, and has received speaker honoraria/travel from Biosense Webster, St. Jude Medical (now Abbott), Boston Scientific, Medtronic, Biotronik, Atricure, Baylis, and Zoll. Drs Bahu and Liu have nothing to disclose. Dr Newton serves as a consultant for Biosense Webster. Dr Sauer receives grants from Biosense Webster and Medtronic and consulting fees from Boston Scientific, Biosense Webster, and Abbott. Dr Goyal receives consulting fees from Biosense Webster and Medtronic. Dr Iyer receives consulting fees from Biosense Webster. Dr Nair serves as a consultant for and receives research grants from Abbott, Boston Scientific, Medtronic, Biosense Webster, and Adagio, and receives research grants from Laminar. Dr Athill receives consulting fees from Boston Scientific, Abbott, and Biosense Webster, and payment/honoraria from Zoll and Janssen. Dr Hussein receives research grants from Boston Scientific and serves on steering committees for Biosense Webster. Dr Whalen serves on the advisory board for Biosense Webster. Dr Melby serves as a consultant for and receives research grants from Biosense Webster. Dr Natale serves as a consultant for Abbott, Biosense Webster, Biotronik, Boston Scientific, and iRhythm.

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society., Competing Interests: Data availability No new data were generated or analyzed in support of this research., (Copyright © 2024. Published by Elsevier Inc.)

Background: Long-term oral anticoagulation is the mainstay therapy for thromboembolic (TE) prevention in patients with atrial fibrillation. However, left atrial appendage occlusion (LAAO) could be a safe alternative to direct oral anticoagulants (DOACs) in patients with a very high TE risk profile., Objective: The purpose of this study was to compare the safety and efficacy of LAAO vs DOACs in patients with atrial fibrillation at very high stroke risk (CHA 2 DS 2 -VASc [congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category] score ≥ 5)., Methods: Data from patients with CHA 2 DS 2 -VASc score ≥ 5 were extracted from a prospective multicenter database. To attenuate the imbalance in covariates between groups, propensity score matching was used (covariates: CHA 2 DS 2 -VASc and HAS-BLED [hypertension, abnormal renal or liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol] scores), which resulted in a matched population of 277 patients per group. The primary end point was a composite of cardiovascular death, TE events, and clinically relevant bleeding during follow-up., Results: Of 2381 patients, 554 very high risk patients were included in the study (mean age 79 ± 7 years; CHA 2 DS 2 -VASc score 5.8 ± 0.9; HAS-BLED score 3.0 ± 0.9). The mean follow-up duration was 25 ± 11 months. A higher incidence of the composite end point was documented with DOACs compared with LAAO (14.9 events per 100 patient-years in the DOAC group vs 9.4 events per 100 patient-years in the LAAO group; P = .03). The annualized clinically relevant bleeding risk was higher with DOACs (6.3% vs 3.2%; P = .04), while the risk of TE events was not different between groups (4.1% vs 3.2%; P = .63)., Conclusion: In high-risk patients, LAAO had a similar stroke prevention efficacy but a significantly lower risk of clinically relevant bleeding when compared with DOACs. The clinical benefit of LAAO became significant after 18 months of follow-up., Competing Interests: Disclosures Dr Burkhardt is a consultant for Biosense Webster and Stereotaxis. Dr Chierchia has received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Boston Scientific, and Acutus Medical. Dr de Asmundis has received research grants on behalf of the center from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips, and Acutus Medical and compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, LivaNova, Boston Scientific, AtriCure, Acutus Medical, and Daiichi Sankyo. Dr Di Biase is a consultant for Biosense Webster, Boston Scientific, Stereotaxis, and St. Jude Medical. Dr Di Biase has received speaker honoraria/travel support from Medtronic, Bristol Meyers Squibb, Pfizer, and Biotronik. Dr Natale has received speaker honoraria from Boston Scientific, Biosense Webster, St. Jude Medical, Biotronik, and Medtronic and is a consultant for Biosense Webster, St. Jude Medical, and Janssen. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Introduction: Both atrial fibrillation (AF) and amyloidosis increase stroke risk. We evaluated the best anticoagulation strategy in AF patients with coexistent amyloidosis., Methods: Consecutive AF patients with concomitant amyloidosis were divided into two groups based on the postablation stroke-prophylaxis approach; group 1: left atrial appendage occlusion (LAAO) in eligible patients and group 2: oral anticoagulation (OAC). Group 1 patients were further divided into Gr. 1A: LAAO + half-does NOAC (HD-NOAC) for 6 months followed by aspirin 81 mg/day and Gr. 1B: LAAO + HD-NOAC. In group 1 patients, with complete occlusion at the 45-day transesophageal echocardiogram, patients were switched to aspirin, 81 mg/day at 6 months. In case of leak, or dense "smoke" in the left atrium (LA) or enlarged LA, they were placed on long-term half-dose (HD) NOAC. Group 2 patients remained on full-dose NOAC during the whole study period., Results: A total of 92 patients were included in the analysis; group 1: 56 and group 2: 36. After the 45-day TEE, 31 patients from group 1 remained on baby-aspirin and 25 on HD NOAC. At 1-year follow-up, four stroke, one TIA and six device-thrombus were reported in group 1A, compared to none in patients in group 1B (5/31 vs. 0/25, p = .03). No bleeding events were reported in group 1, whereas group 2 had five bleeding events (one subdural hematoma, one retinal hemorrhage, and four GI bleedings). Additionally, one stroke was reported in group 2 that happened during brief discontinuation of OAC., Conclusion: In patients with coexistent AF and amyloidosis, half-dose NOAC following LAAO was observed to be the safest stroke-prophylaxis strategy., (© 2024 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.)

Background: High-voltage pulses can cause hemolysis., Objectives: The authors evaluated the occurrence of hemoglobinuria after pulsed-field ablation (PFA) and its impact on renal function in patients with atrial fibrillation (AF)., Methods: A consecutive series of patients with AF undergoing PFA were included in this analysis. The initial patients who did not receive postablation hydration immediately after the procedure were classified as group 1 (n = 28), and the rest of the study patients who received planned fluid infusion (0.9% sodium chloride ≥2 L) after the procedure were categorized as group 2 (n = 75)., Results: Of the 28 patients in group 1, 21 (75%) experienced hemoglobinuria during the 24 hours after catheter ablation. The mean postablation serum creatinine (S-Cr) was significantly higher than the baseline value in those 21 patients (1.46 ± 0.28 mg/dL vs 0.86 ± 0.24 mg/dL, P < 0.001). Of those 21 patients, 4 (19%) had S-Cr. >2.5 mg/dL (mean: 2.95 ± 0.21 mg/dL). The mean number of PF applications was significantly higher in those 4 patients than in the other 17 patients experiencing hemoglobinuria (94.63 ± 3.20 vs 46.75 ± 9.10, P < 0.001). In group 2 patients, no significant changes in S-Cr were noted. The group 2 patients received significantly higher amounts of fluid infusion after catheter ablation than did those in group 1 (2,082.50 ± 258.08 mL vs 494.01 ± 71.65 mL, P < 0.001). In multivariable analysis, both hydration (R 2  = 0.63, P < 0.01) and number of PFA applications (R 2  = 0.33, P < 0.01) were independent predictors of postprocedure acute kidney injury., Conclusions: On the basis of our findings, both the number of PFA applications and postablation hydration were independent predictors of renal insult that could be prevented using planned fluid infusion immediately after the procedure., Competing Interests: Funding Support and Author Disclosures Dr. Chierchia has received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Boston Scientific, and Acutus Medical. Dr. Burkhardt is a consultant for Biosense Webster and Stereotaxis. Dr. Di Biase is a consultant for Biosense Webster, Boston Scientific, Stereotaxis, and St. Jude Medical and has received speaker honoraria from Medtronic, Atricure, EPiEP, and Biotronik. Dr. de Asmundis has received research grants on behalf of the center from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips, and Acutus and compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Livanova, Boston Scientific, Atricure, Acutus Medical, and Daiichi Sankyo. Dr. Dello Russo is a consultant for Abbott Medical. Dr, Natale is a consultant for Abbott, Biosense Webster, Biotronik, Boston Scientific, and iRhythm. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Studies have reported development of pulmonary hypertension (PH) secondary to reduced LA compliance following AF ablation., Objectives: This study aimed to compare the risk of worsening of baseline PH between non-paroxysmal AF patients undergoing pulsed-field ablation (PFA) and standard radiofrequency ablation (RFA)., Methods: This multicenter study included 28 nonparoxysmal AF patients with PH undergoing a PFA-based ablation procedure after >1 failed RFA. A cohort of 28 AF patients with PH, scheduled for repeat RFA, 1:1 propensity-score matched using a multivariable logistic model, were used as the comparator group. Right heart catheterization and echocardiography were performed before and after the procedure to assess the pulmonary artery pressure (PAP). PH was defined as resting mean PAP of >20 mm Hg., Results: The baseline characteristics of the PFA and propensity-matched RFA groups were comparable. The mean PAP assessments at baseline, follow-up, and change from baseline were analyzed. The groups had comparable baseline mean pulmonary artery pressures (mPAP) (P = 0.177). After adjustment for baseline mPAP in an analysis of covariance model, the least-squares means change at 3 months after ablation was -1.71 ± 1.03 mm Hg and 19.67 ± 1.03 mm Hg in PFA and RFA, respectively (P <0.001)., Conclusions: In this propensity-matched population, no worsening of mPAP was detected following pulsed-field ablation in patients with pre-existing PH undergoing a repeat procedure for recurrence., Competing Interests: Funding Support and Author Disclosures Dr Chierchia has received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Boston Scientific, and Acutus Medical. Dr Dello Russo has served as a consultant for Abbott Medical. Dr Burkhardt is a consultant for Biosense Webster and Stereotaxis. Dr Di Biase is a consultant for Biosense Webster, Boston Scientific, Stereotaxis, and St. Jude Medical; and has received speaker honoraria from Medtronic, Atricure, EPiEP, and Biotronik. Dr de Asmundis has received research grants on behalf of the center from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips, and Acutus; and compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Livanova, Boston Scientific, Atricure, Acutus Medical, and Daiichi Sankyo. Dr Natale has been a consultant for Abbott, Biosense Webster, Biotronik, Boston Scientific, and iRhythm. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: Different disease processes can combine to cause atrial fibrillation (AF). Their contribution to recurrent AF after ablation in patients is not known. Cardiovascular processes associated with recurrent AF after AF ablation were determined by quantifying biomolecules related to inflammation, metabolism, proliferation, fibrosis, shear stress, atrial pressure, and others in the AXAFA biomolecule study., Methods and Results: Twelve circulating cardiovascular biomolecules (ANGPT2, BMP10, CA125, hsCRP, ESM1, FABP3, FGF23, GDF15, IGFBP7, IL6, NT-proBNP, and hsTnT) were quantified in plasma samples obtained prior to a first AF ablation using high-throughput, high-precision assays. Cox regression was used to identify biomolecules associated with recurrent AF during the first 3 months after AF ablation. In 433 patients (64 years [58, 70]; 33% women), baseline concentrations of ANGPT2, BMP10, hsCRP, FGF23, FABP3, GDF15, and NT-proBNP were elevated in patients with recurrent AF (120/433; 28%). After adjustment for 11 clinical features and randomized treatment, elevated NT-proBNP [hazard ratio (HR) 1.58, 95% confidence interval (1.29, 1.94)], ANGPT2 [HR 1.37, (1.12, 1.67)], and BMP10 [HR 1.24 (1.02, 1.51)] remained associated with recurrent AF. Concentrations of ANGPT2, BMP10, and NT-proBNP decreased in patients who remained arrhythmia free, but not in patients with recurrent AF, highlighting their connection to AF. The other eight biomarkers showed unchanged concentrations., Conclusion: Elevated concentrations of ANGPT2, BMP10, and NT-proBNP are associated with recurrent AF after a first AF ablation, suggesting that processes linked to disturbed cardiomyocyte metabolism, altered atrial shear stress, and increased load contribute to AF after AF ablation in patients., Competing Interests: Conflict of interest: K.G.H. reports lecture fees/advisory board fees from Abbott, Alexion, Amarin, AstraZeneca, Bayer, Biotronik, Boehringer Ingelheim, Bristol Myers Squibb, Daiichi Sankyo, Edwards Lifesciences, Medtronic, Pfizer, Premier Research, SUN Pharma, and W. L. Gore & Associates. R.B.S. has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme under the grant agreement no. 648131, from the European Union’s Horizon 2020 research and innovation programme under the grant agreement no. 847770 (AFFECT-EU), German Center for Cardiovascular Research (DZHK e.V.; 81Z1710103), German Ministry of Research and Education (BMBF 01ZX1408A), and ERACoSysMed3 (031L0239). R.B.S. has received lecture fees and advisory board fees from BMS/Pfizer outside this work. P.K. receives research support for basic, translational, and clinical research projects from the European Union, British Heart Foundation, Leducq Foundation, Medical Research Council (UK), and German Centre for Cardiovascular Research, from several drug and device companies active in atrial fibrillation, and has received honoraria from several such companies in the past, but not in the last 3 years. P.K. is listed as inventor on two patents held by University of Birmingham (Atrial Fibrillation Therapy WO 2015140571, Markers for Atrial Fibrillation WO 2016012783). U.S. received research grants from the Netherlands Heart Foundation (CVON2014-09, RACE V Reappraisal of Atrial Fibrillation: Interaction between hyperCoagulability, Electrical remodeling, and Vascular Destabilisation in the Progression of AF) and the European Union (ITN Network Personalize AF: Personalized Therapies for Atrial Fibrillation: a translational network, grant number 860974; CATCH ME: Characterizing Atrial fibrillation by Translating its Causes into Health Modifiers in the Elderly, grant number 633196; MAESTRIA: Machine Learning Artificial Intelligence Early Detection Stroke Atrial Fibrillation, grant number 965286; REPAIR: Restoring cardiac mechanical function by polymeric artificial muscular tissue, grant number 952166). U.S. received consultancy fees or honoraria from Università della Svizzera Italiana (USI, Switzerland), Roche Diagnostics (Switzerland), EP Solutions Inc. (Switzerland), Johnson & Johnson Medical Limited (UK), and YourRhythmics BV. U.S. is co-founder and shareholder of YourRhythmics BV, a spin-off company of the University Maastricht. U.-H.W.-T. is an employee of Roche Diagnostics. T.Z. received funding from the German Science Foundation, German Center for Cardiovascular Research (DZHK e.V.; 81Z1710101, partner site project), The European Union euCanSHare project (grand agreement 825903), the ERA CVD project PREMED-CAD (FKZ01KL1807), and the ERA PerMed project (01KU1910B) outside this work. L.M. reports honoraries as consultant, lecturer, and advisory board from Boston Scientific, Abbott Medical, Johnson & Johnson, and Medtronic. He is a shareholder of Galgo Medical SL. J.P. is supported by R01AG074185 from the National Institutes of Aging, grants for clinical research from Abbott, American Heart Association, the Association for the Advancement of Medical Instrumentation, Bayer, Boston Scientific, iRhythm, and Philips, and serves as a consultant to Abbott, AbbVie, Bayer, Biotronik, Boston Scientific, Bristol Myers Squibb, Element Science, Itamar Medical, LivaNova, Medtronic, Milestone, ElectroPhysiology Frontiers, ReCor, Sanofi, Philips, and Up-to-Date. The other authors have nothing to disclose. L.F. received institutional research support from EU Horizon 2020 CATCH ME (grant agreement number 633196), and MAESTRIA (grant agreement number 965286). L.F. has received funding from Accelerator Award by the British Heart Foundation AA/18/2/34218. L.F. is further part-funded by National Institute for Health and Care Research (NIHR) award 1002898 (APRAISE-AS) at University of Birmingham, AFFECT-EU grant agreement number 847770 and German Center for Cardiovascular Research (DZHK)., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Electrophysiological and interventional procedures have been increasingly used to reduce morbidity and mortality in patients experiencing cardiovascular diseases. Although antithrombotic therapies are critical to reduce the risk of stroke or other thromboembolic events, they can nonetheless increase the bleeding hazard. This is even more true in an aging population undergoing cardiac procedures in which the combination of oral anticoagulants and antiplatelet therapies would further increase the hemorrhagic risk. Hence, the timing, dose, and combination of antithrombotic therapies should be carefully chosen in each case. However, the maze of society guidelines and consensus documents published so far have progressively led to a hazier scenario in this setting. Aim of this review is to provide-in a single document-a quick, evidenced-based practical summary of the antithrombotic approaches used in different cardiac electrophysiology and interventional procedures to guide the busy clinician and the cardiac proceduralist in their everyday practice., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: Left atrial appendage (LAA) imaging is critical during percutaneous occlusion procedures. 3D-intracardiac echocardiography (ICE) features direct visualization of LAA from multiple cross-sectional planes at a time. We aimed at reporting procedural success of 3D-ICE-guided LAA occlusion and the correlation between pre-procedural transoesophageal echocardiography (TEE) and intraprocedural 3D-ICE for LAA sizing., Methods and Results: Among 274 patients undergoing left atrial appendage occlusion (LAAO) with a Watchman FLX, periprocedural ICE guidance was achieved via a commercially available 2D-ICE catheter (220 patients) or a novel (NUVISION™) 3D-ICE one (54 patients). Primary endpoint was a composite of procedural success and LAA sealing at follow-up TEE. Secondary endpoint was a composite of periprocedural device recapture/resizing plus presence of leaks ≥ 3 mm at follow-up TEE. 3D-ICE measurements of maximum landing zone correlated highly with pre-procedural TEE reference values [Pearson's: 0.94; P < 0.001; bias: -0.06 (-2.39, 2.27)]. The agreement between 3D-ICE-based device selection and final device size was 96.3% vs. 79.1% with 2D-ICE (P = 0.005). The incidence of the primary endpoint was 98.1% with 3D-ICE and 97.3% with 2D-ICE (P = 0.99). 2D-ICE patients had a trend towards a higher incidence of periprocedural device recapture/redeployment (31.5% vs. 44.5%; P = 0.09). The secondary endpoint occurred in 31.5% of 3D-ICE patients vs. 45.9% of 2D-ICE ones (P = 0.065)., Conclusion: Intracardiac echocardiography-guided LAAO showed a very high success, with no major adverse events. A very high level of agreement for LAA sizing was found between pre-procedural TEE and periprocedural 3D-ICE. 3D-ICE performed significantly better than 2D-ICE for FLX size selection and may provide better guidance during device deployment., Competing Interests: Conflict of interest: G.-B.C. received compensation from Medtronic, Abbott, Biotronik, Boston Scientific, and Acutus Medical. C.d.A. received research grants on behalf of the centre from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips, and Acutus. D.J.B. is a consultant for Biosense Webster and Stereotaxis. L.D.B. is a consultant for Biosense Webster, Boston Scientific, Stereotaxis, and St. Jude Medical. A.N. received speaker honoraria from Boston Scientfic, Biosense Webster, St. Jude Medical, Biotronik, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Left atrial catheter ablation is well established in patients with symptomatic atrial fibrillation (AF) but associated with risk of embolism to the brain. The present analysis aims to assess the impact of diffusion-weighted imaging (DWI) slice thickness on the rate of magnetic resonance imaging (MRI)-detected ischaemic brain lesions after ablation., Methods and Results: AXAFA-AFNET 5 trial (NCT02227550) participants underwent MRI using high-resolution (hr) DWI (slice thickness: 2.5-3 mm) and standard DWI (slice thickness: 5-6 mm) within 3-48 h after ablation. In 321 patients with analysable brain MRI (mean age 64 years, 33% female, median CHA2DS2-VASc 2), hrDWI detected at least one acute brain lesion in 84 (26.2%) patients and standard DWI in 60 (18.7%; P < 0.01) patients. High-resolution diffusion-weighted imaging detected more lesions compared to standard DWI (165 vs. 104; P < 0.01). The degree of agreement for lesion confirmation using hrDWI vs. standard DWI was substantial (κ = 0769). Comparing the proportion of DWI-detected lesions, lesion distribution, and total lesion volume per patient, there was no difference in the cohort of participants undergoing MRI at 1.5 T (n = 52) vs. 3 T (n = 269)., Conclusion: The pre-specified AXAFA-AFNET 5 sub-analysis revealed significantly increased rates of MRI-detected acute brain lesions using hrDWI instead of standard DWI in AF patients undergoing ablation. In comparison to DWI slice thickness, MRI field strength had a no significant impact in the trial. Comparing the varying rates of ablation-related MRI-detected brain lesions across previous studies has to consider these technical parameters. Future studies should use hrDWI, as feasibility was demonstrated in the multicentre AXAFA-AFNET 5 trial., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Introduction: Earlier studies have shown a clear association between severity of human immunodeficiency virus (HIV) infection and incident atrial fibrillation (AF). We present the long-term outcome of catheter ablation (CA) and electrophysiological characteristics in HIV+ AF patients., Methods: This study evaluated 1438 consecutive AF patients [31 (2.15%) with HIV and 1407 (97.8%) without HIV diagnosis] undergoing their first CA at our center. A total of 31 HIV patients and 31 controls were generated by propensity matching, based on calculated risk factor scores, using a logistic model. During first procedure, all received isolation of pulmonary vein (PV) + posterior wall and superior vena cava. Non-PV triggers, defined as ectopic triggers originating from sites other than PVs, were identified at the redo ablation with high-dose isoproterenol challenge., Results: Clinical characteristics were not different between the groups. When compared to the control, by the end of 5 years after the first procedure, recurrence was significantly greater in HIV group [100% vs. 54%, p < .001]. Among patients that underwent redo ablation non-PV triggers were higher in HIV group [93.5% vs. 54%, p < .001], and most frequently originated from the coronary sinus [67.7% vs. 45.2%, p < .001] and left atrial appendage [41.9% vs. 25.8%, p < .001]. After focal ablation of non-PV trigger, no difference in arrhythmia recurrence between two groups [80.6% vs. 87.1%, p = .753] at 1-year follow up was found., Conclusion: Our findings suggest that non-PV triggers are highly prevalent in HIV+ AF patients resulting in higher rate of the mid- and long-term arrhythmia recurrence., (© 2023 Wiley Periodicals LLC.)

Introduction: The prospective, nonrandomized, multicenter Q-FFICIENCY study demonstrated the safety and 12-month efficacy of paroxysmal atrial fibrillation (AF) ablation with the novel QDOT MICRO temperature-controlled, contact force-sensing, radiofrequency (RF) catheter. Participants underwent pulmonary vein isolation with very high-power short-duration (vHPSD) mode (90 W, ≤4 s) alone or combined with conventional-power temperature-controlled (CPTC) mode (25-50 W). This study aimed to assess quality-of-life (QOL) and healthcare utilization (HCU) benefits experienced by Q-FFICIENCY study participants., Methods: Besides evaluating procedural efficiency, QOL and HCU were assessed through 12 months postablation via Atrial Fibrillation Effect on Quality-of-Life Tool (AFEQT) score, antiarrhythmic drug (AAD) use, and incidence of cardioversion and cardiovascular hospitalization., Results: Of 191 participants enrolled, 166 were ablated with the new catheter. Compared to baseline, statistically significant, clinically meaningful improvements in composite and subcategories of AFEQT scores were observed at 3 months and sustained through 12 months (12-month increase, 29.3-44.2 points). Class I/III AAD use decreased from 97.6% (162/166) at baseline to 19.6% (31/158) during Months 6-12, representing a significant 79.9% reduction. The cardioversion rate significantly declined by 93.9% from 31.3% (12 months preablation) to 1.9% (evaluation period). One-year Kaplan-Meier estimates of freedom from all-cause and cardiovascular hospitalization were 80.9% (95% confidence interval [CI], 74.8%-86.9%) and 88.8% (95% CI, 84.0%-93.7%), respectively., Conclusions: Paroxysmal AF ablation with the novel temperature-controlled RF catheter in vHPSD mode, alone or with CPTC mode, led to clinically meaningful improvement in QOL and significant reduction in AAD use, cardioversion, and cardiovascular hospitalization., (© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.)

Background: Pulsed field ablation (PFA) has emerged as an alternative to radiofrequency ablation. However, data on focal point-by-point PFA are scarce. The aim of this study was to compare lesion durability and collateral damage between focally delivered unipolar/biphasic PFA versus radiofrequency in swine., Methods: Eighteen swine were randomized to low-dose PFA, high-dose PFA, and radiofrequency using a multimodality generator. Radiofrequency delivered by market-available generator served as control group. A contact force-sensing catheter was used to focally deliver PFA/radiofrequency at the pulmonary veins and other predefined sites in the atria. Animals were remapped postprocedurally and 28 days postablation to test lesion durability followed by gross necroscopy and histology., Results: All targeted sites were successfully ablated (contact force value, 13.9±4.1 g). Follow-up remapping showed persistent pulmonary vein isolation in all animals (100%) with lesion durability at nonpulmonary vein sites proven in most (98%). Regardless of the energy source used, the lesion size was similar across the study groups. Transmurality was achieved in 95% of targeted sites and 100% at pulmonary veins. On histology, PFA animals showed more mature scar formation than their radiofrequency counterpart without myocardial necrosis or inflammation. Finally, no sign of collateral damage was observed in any of the groups., Conclusions: In a randomized preclinical study, focally delivered unipolar/biphasic PFA guided by contact force values was associated with durable lesions on chronic remapping and with mature scar formation on histology without signs of collateral injury on necroscopy. Further studies are needed to investigate the long-term feasibility of this new approach to atrial fibrillation treatment., Competing Interests: Disclosures Dr Di Biase is a consultant for Stereotaxis, Biosense Webster, Boston Scientific, Abbott Medical, and I-Rhythm and has received speaker honoraria/travel from Medtronic, Atricure, Biotronik, Baylis Medical, and Zoll. V. Grupposo, Drs Marazzato, Farshchi-Heydari, Sharma, C. Beeckler, and Dr Govari are Biosense Webster Employees. The other authors report no conflicts.

Introduction: Catheter ablation of atrial fibrillation (AF) has emerged as the most effective therapy. However, rare anatomical abnormalities such as situs inversus totalis, dextrocardia, or interrupted inferior vena cava can make ablation challenging., Methods and Results: We report a case of a 55-year-old woman with situs inversus totalis, dextrocardia, surgical atrial septal defect repair, left-sided dual chamber pacemaker in place, and symptomatic recurrent persistent AF who underwent successful pulmonary vein and posterior wall isolation by the superior access from the left internal jugular vein., Conclusions: It is a feasible and safe approach with support of transesophageal echocardiography and multiple emerging technologies., (© 2023 Wiley Periodicals LLC.)

Aims: Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist and share an increased risk of thrombo-embolism (TE). CKD concomitantly predisposes towards a pro-haemorrhagic state. Our aim was to evaluate the prognostic value of CKD in patients undergoing percutaneous left atrial appendage occlusion (LAAO)., Methods and Results: A total of 2124 consecutive AF patients undergoing LAAO were categorized into CKD stage 1+2 (n = 1089), CKD stage 3 (n = 796), CKD stage 4 (n = 170), and CKD stage 5 (n = 69) based on the estimated glomerular filtration rate at baseline. The primary endpoint included cardiovascular (CV) mortality, TE, and major bleeding. The expected annual TE and major bleeding risks were estimated based on the CHA2DS2-VASc and HAS-BLED scores. 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 CKD (P = 0.14). The mean follow-up period was 13 ± 7 months (2226 patient-years). 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). Left atrial appendage occlusion led to a TE risk reduction (RR) of 72, 66, 62, and 41% in each group. The relative RR 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 RR in the incidence of TE and major bleeding was consistent across CKD groups., Competing Interests: Conflict of interest: G.B.C. received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Boston Scientific, and Acutus Medical. C.dA. received research grants on behalf of the centre from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips, and Acutus and compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Livanova, Boston Scientific, Atricure, Acutus Medical, and Daiichi Sankyo. J.C.G. is a consultant and has received speaker fees from Boston Scientific, Abbott, Medtronic, Biotronik, Pfizer, Bayer, Novartis, Daiichi Sankyo, and Boehringer Ingelheim. M.M. serves as a consultant for Boston Scientific and Abbott. L.D.B. is a consultant for Stereotaxis, Biosense Webster, Boston Scientific, Rhythm Management, and Abbott Medical. J.S. is a consultant for Boston Scientific, Abbott, Baylis, Gore, and FEops, and a proctor for Boston Scientific and Abbott. D.G. is a consultant for Boston Scientific, Abbot, Acutus, and Biosense Webster. A.N. is as a consultant for Abbott, Biosense Webster, Inc., Biotronik, Boston Scientific, Baylis, and Medtronic. The remaining authors have nothing to disclose., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Standardized data definitions are essential for monitoring and assessment of care and outcomes in observational studies and randomized controlled trials (RCTs). The European Unified Registries for Heart Care Evaluation and Randomized Trials (EuroHeart) project of the European Society of Cardiology aimed to develop contemporary data standards for atrial fibrillation/flutter (AF/AFL) and catheter ablation., Methods and Results: We used the EuroHeart methodology for the development of data standards and formed a Working Group comprising 23 experts in AF/AFL and catheter ablation registries, as well as representatives from the European Heart Rhythm Association and EuroHeart. We conducted a systematic literature review of AF/AFL and catheter ablation registries and data standard documents to generate candidate variables. We used a modified Delphi method to reach a consensus on a final variable set. For each variable, the Working Group developed permissible values and definitions, and agreed as to whether the variable was mandatory (Level 1) or additional (Level 2). In total, 70 Level 1 and 92 Level 2 variables were selected and reviewed by a wider Reference Group of 42 experts from 24 countries. The Level 1 variables were implemented into the EuroHeart IT platform as the basis for continuous registration of individual patient data., Conclusion: By means of a structured process and working with international stakeholders, harmonized data standards for AF/AFL and catheter ablation for AF/AFL were developed. In the context of the EuroHeart project, this will facilitate country-level quality of care improvement, international observational research, registry-based RCTs, and post-marketing surveillance of devices and pharmacotherapies., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Implantable cardiac monitors are routinely placed for long-term monitoring (LTM) after a period of negative short-term monitoring (STM) to increase atrial fibrillation (AF) detection after a cryptogenic stroke or transient ischemic attack (TIA). Optimizing AF monitoring after a cryptogenic stroke is critical to improve outcomes and reduce costs. We sought to compare the diagnostic yield of STM versus LTM, assess the impact of routine STM on hospitalization length of stay, and perform a financial analysis comparing the current model to a theoretical model wherein patients can proceed directly to LTM. Our retrospective observational cohort study analyzed patients admitted to Montefiore Medical Center between May 2017 and June 2022 with a primary diagnosis of cryptogenic stroke or TIA who underwent Holter device monitoring. Of 396 subjects, STM detected AF in 10 (2.5%) compared with a diagnostic yield of 14.6% for LTM (median time to diagnosis of 76 days). Of the 386 patients with negative STM, 130 (33.7%) received an implantable cardiac monitor while an inpatient, and 256 (66.3%) did not. We calculated a point estimate of 1.67 days delay of discharge attributable to the requirement for STM to precede LTM. Our model showed that the expected cost per patient in the STM-first paradigm is $28,615.33 versus $27,111.24 in the LTM-or-STM paradigm. Considering the relatively lower diagnostic yield of STM and its association with a longer length of stay and higher costs, it may be reasonable to proceed directly to LTM to optimize AF detection after a cryptogenic stroke or TIA., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Published by Elsevier Inc.)

Introduction: Complex atrial tachyarrhythmias (CATs) are commonly observed in patients with prior catheter ablation or cardiac surgery. These arrhythmias are challenging to map and ablate. Historically, entrainment mapping was utilized to characterize CAT. With the advent of high-definition mapping (HDM), full visualization of the CAT circuit is possible which may obviate the need for entrainment mapping., Methods: We sought to investigate the outcomes of catheter ablation of CAT guided only by HDM. Consecutive patients who underwent CAT ablation from 2017 to 2021 were included in our study (excluding right atrial tachyarrhythmias). Patients were sorted by the type of mapping performed. Group I consisted of patients where HDM alone was utilized with no attempt of entrainment. Group II consisted of patients where both entrainment and HDM were utilized., Results: A total of 67 patients were included in our study, with 40 patients in HDM group (I) and 27 patients in entrainment group (II). No statistically significant difference regarding 1-year freedom from atrial arrhythmias was found between the two groups (80% vs 77.8%, p = 0.819). Four CATs were terminated by entrainment during procedure versus none in the HDM-only group (p = 0.011)., Conclusions: CAT ablation with HDM alone yielded similar 1-year freedom from atrial arrhythmias compared to ablation with HDM and entrainment. Entrainment combined with HDM was associated with higher undesired CAT interruption rate. Further validation is needed with randomized control trials., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Aims: Intracardiac echocardiography (ICE) is a useful but operator-dependent tool for left atrial (LA) anatomical rendering during atrial fibrillation (AF) ablation. The CARTOSOUND FAM Module, a new deep learning (DL) imaging algorithm, has the potential to overcome this limitation. This study aims to evaluate feasibility of the algorithm compared to cardiac computed tomography (CT) in patients undergoing AF ablation., Methods and Results: In 28 patients undergoing AF ablation, baseline patient information was recorded, and three-dimensional (3D) shells of LA body and anatomical structures [LA appendage/left superior pulmonary vein/left inferior pulmonary vein/right superior pulmonary vein/right inferior pulmonary vein (RIPV)] were reconstructed using the DL algorithm. The selected ultrasound frames were gated to end-expiration and max LA volume. Ostial diameters of these structures and carina-to-carina distance between left and right pulmonary veins were measured and compared with CT measurements. Anatomical accuracy of the DL algorithm was evaluated by three independent electrophysiologists using a three-anchor scale for LA anatomical structures and a five-anchor scale for LA body. Ablation-related characteristics were summarized. The algorithm generated 3D reconstruction of LA anatomies, and two-dimensional contours overlaid on ultrasound input frames. Average calculation time for LA reconstruction was 65 s. Mean ostial diameters and carina-to-carina distance were all comparable to CT without statistical significance. Ostial diameters and carina-to-carina distance also showed moderate to high correlation (r = 0.52-0.75) except for RIPV (r = 0.20). Qualitative ratings showed good agreement without between-rater differences. Average procedure time was 143.7 ± 43.7 min, with average radiofrequency time 31.6 ± 10.2 min. All patients achieved ablation success, and no immediate complications were observed., Conclusion: DL algorithm integration with ICE demonstrated considerable accuracy compared to CT and qualitative physician assessment. The feasibility of ICE with this algorithm can potentially further streamline AF ablation workflow., Competing Interests: Conflict of interest: L.D.B. is a consultant for Stereotaxis, Biosense Webster, Boston Scientific, Abbott Medical; has received speaker honoraria/travel from Medtronic, Atricure, Biotronik, Baylis Medical, and Zoll. G.H., D.H., R.A.M., J.A., G.C., and R.U. are employees of Biosense Webster, Inc. The remaining authors report no conflict of interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

The overall survival in patients undergoing lung transplantation is poor. Although postsurgical atrial arrhythmias seem to play a major role in the morbidity and mortality of this population, data regarding the clinical and interventional management of this complication are still controversial. Through a review of the literature in the field, we observed that not only the surgical technique is clearly arrhythmogenic, but the new administration of peri-procedure beta-blockers and amiodarone for arrhythmia prevention and treatment, respectively, seems harmful in these postsurgical patients. However, low-dose beta-blockers administered after surgery seem feasible in arrhythmia prevention in specific patient subgroups, and, aside from amiodarone, alternative antiarrhythmic agents can be safely and effectively used to treat symptomatic patients on top of adequate rate control. Finally, as to complex atrial arrhythmias occurring late after lung transplant surgery, radiofrequency catheter ablation seems a feasible treatment option. In light of this evidence and considering the absence of clear recommendations in the field, we suggest a practical approach that may help the clinician in the management of this postsurgical complication. However, as most of these considerations are drawn from small-sized and retrospective studies, more evidence is needed in the future to clarify which medical and interventional strategies may best treat these postsurgical arrhythmias and thus potentially improve the outcome of these frail patients., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Acute pericarditis is a known complication of ablation procedures for atrial fibrillation (AF)., Objectives: This study aimed to evaluate the benefits of colchicine monotherapy in terms of reducing the risk of pericarditis and related hospitalization rate in AF patients undergoing catheter ablation., Methods: Consecutive AF patients undergoing first catheter ablation were classified into 3 groups based on their colchicine use: Group 1: no colchicine; group 2: colchicine from 7 days before to 1 month after ablation; and group 3: colchicine from the day of the procedure to 1 month after. Standard institutional protocol was used to follow all patients for 1 year., Results: A total of 1,075 patients were classified into groups 1 (n = 607), 2 (n = 213), and 3 (n = 255). Symptoms of acute pericarditis were reported in 129 patients (12%): group 1: n = 106 (17.5%); group 2: n = 4 (1.9%); and group 3: n = 19 (7.5%); P < 0.001. Rate of mild-moderate as well as severe pericarditis were significantly lower in group 2. In the multivariable regression analysis, pre- and post-ablation colchicine use was seen to be associated with significantly lower risk of acute pericarditis and related hospitalization compared with the other 2 groups. In addition, at 1-year follow-up, arrhythmia-free survival rate was significantly higher in paroxysmal AF patients receiving colchicine compared with the no-colchicine population., Conclusions: Colchicine therapy starting 7 days before to 1 month after the ablation procedure was associated with significantly lower risk of acute pericarditis and related hospitalization. In addition, paroxysmal AF patients receiving colchicine had a higher arrhythmia-free survival rate compared with those not receiving colchicine., Competing Interests: Funding Support and Author Disclosures Dr Natale is a consultant for Abbott, Baylis, Biosense Webster, Biotronik, Boston Scientific, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: Prevalent atrial fibrillation (AF) is associated with excess cardiovascular (CV) death (D) and hospitalizations (H) in heart failure (HF) with preserved ejection fraction (pEF). We evaluated if it had an independent role in excess CVD in HFpEF and studied its impact on cause-specific mortality and HF morbidity., Methods and Results: We used propensity score-matched (PSM) cohorts from the TOPCAT Americas trial to account for confounding by other co-morbidities. Two prevalent AF presentations at study entry were compared: (i) subjects with Any AF event by history or on electrocardiogram (ECG) with PSM subjects without an AF event and (ii) subjects in AF on ECG with PSM subjects in sinus rhythm. We analyzed cause-specific modes of death and HF morbidity during a mean follow-up period of 2.9 years. A total of 584 subjects with Any AF event and 418 subjects in AF on ECG were matched. Any AF was associated with increased CVH [hazard ratio (HR) 1.33, 95% confidence interval (CI) 1.11-1.61, P = 0.003], HFH (HR 1.44, 95% CI 1.12-1.86, P = 0.004), pump failure death (PFD) (HR 1.95, 95% CI 1.05-3.62, P = 0.035), and HF progression from New York Heart Association (NYHA) classes I/II to III/IV (HR 1.30, 95% CI 1.04-1.62, P = 0.02). Atrial fibrillation on ECG was associated with increased risk of CVD (HR 1.46, 95% CI 1.02-2.09, P = 0.039), PFD (HR 2.21, 95% CI 1.11-4.40, P = 0.024), and CVH and HFH (HR 1.37, 95% CI 1.09-1.72, P = 0.006 and HR 1.65, 95% CI 1.22-2.23, P = 0.001, respectively). Atrial fibrillation was not associated with risk of sudden death. Both Any AF and AF on ECG cohorts were associated with PFD in NYHA class III/IV HF., Conclusion: Prevalent AF can be an independent risk factor for adverse CV outcomes by its selective association with worsening HF, HFH, and PFD in HFpEF. Prevalent AF was not associated with excess sudden death risk in HFpEF. Atrial fibrillation was also associated with HF progression in early symptomatic HFpEF and PFD in advanced HFpEF., Trial Registration: TOPCAT trial is registered at www.clinicaltrials.gov:identifier NCT00094302., Competing Interests: Conflict of interest: S.S. was a member of the Steering Committee of the TOPCAT trial. The Electrophysiology Research Foundation received a research grant as an investigational site for the TOPCAT trial. All remaining authors have declared no conflicts of interest with the subject of this manuscript., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Thromboembolic events (TEE) associated with atrial fibrillation (AF) are highly recurrent and usually severe, causing permanent disability or, even, death. Previous data consistently showed significantly lower TEE in anticoagulated patients. While warfarin, a vitamin K antagonist, is still used worldwide, direct-acting oral anticoagulants (DOACs) have shown noninferiority to warfarin in the prevention of TEE, and represent, to date, the preferred treatment. DOACs present favorable pharmacokinetic, safety and efficacy profiles, especially among vulnerable patients including the elderly, those with renal dysfunction or previous TEE. Yet, regarding specific settings of AF patients it is unclear whether oral anticoagulation therapy is beneficial, or otherwise it is the maintenance of sinus rhythm, mostly achieved through a catheter ablation-based rhythm control strategy, that prevents the causal complications linked to AF. While it is known that low-risk patients [CHA2DS2-VASc 0 (males), or score of 1 (females)] present low ischemic stroke or mortality rates (<1%/year), it remains unclear whether they need any prophylaxis. Furthermore, the appropriate anticoagulation regimen for those individuals requiring cardioversion, either pharmacologic or electric, as well as peri-procedural anticoagulation in patients undergoing trans-catheter ablation that nowadays encompasses different energies, are still a matter of debate. In addition, AF concomitant with other clinical conditions is discussed and, lastly, the choice of prescribing anticoagulation to asymptomatic patients diagnosed with subclinical AF at either wearable or implanted devices. The aim of this review will be to provide an update on current strategies in the above-mentioned settings, and to suggest possible therapeutic options, finally focusing on AF-related cognitive decline., (Copyright © 2023 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Background: QDOT MICRO (QDM) is a novel contact force-sensing catheter optimized for temperature-controlled radiofrequency (RF) ablation. The very high-power short-duration (vHPSD) algorithm modulates power, maintaining target temperature during 90 W ablations for ≤4 seconds., Objectives: This study aims to evaluate safety and 12-month effectiveness of the QDM catheter in paroxysmal atrial fibrillation (AF) ablation using the vHPSD mode combined with conventional-power temperature-controlled (CPTC) mode., Methods: In this prospective, multicenter, nonrandomized study, patients with drug-refractory, symptomatic paroxysmal AF underwent pulmonary vein (PV) isolation with QDM catheter with vHPSD as primary ablation mode, with optional use of the CPTC mode (25 to 50 W) for PV touch-up or non-PV ablation. The primary safety endpoint was incidence of primary adverse events within ≤7 days of ablation. The primary effectiveness endpoint was freedom from documented atrial tachyarrhythmia recurrence and acute procedural, repeat ablation, and antiarrhythmic drug failure., Results: Of 191 enrolled participants, 166 had the catheter inserted, received RF ablation, and met eligibility criteria. Median procedural, RF application for ablating PVs, and fluoroscopy times were 132.0, 8.0, and 9.1 minutes, respectively. The primary adverse event rate was 3.6%. Imaging conducted in a subset of participants (n = 40) at 3 months did not show moderate or severe PV stenosis. The Kaplan-Meier estimated 12-month rate for primary effectiveness success was 76.7%; freedom from atrial tachyarrhythmia recurrence was 82.1%; clinical success (freedom from symptomatic recurrence) was 86.0%; and freedom from repeat ablation was 92.1%., Conclusions: Temperature-controlled paroxysmal AF ablation with the novel QDM catheter in vHPSD mode (90 W, ≤4 seconds), alone or with CPTC mode (25 to 50 W), is highly efficient and effective without compromising safety. (Evaluation of QDOT MICRO Catheter for Pulmonary Vein Isolation in Subjects With Paroxysmal Atrial Fibrillation [Q-FFICIENCY]; NCT03775512)., Competing Interests: Funding Support and Author Disclosures This study was supported by Biosense Webster, Inc. Dr Osorio has received grants from Biosense Webster, Inc, and Abbott; has received consulting fees from Biosense Webster, Inc, Boston Scientific, and Medtronic; and has received payments or honoraria for lectures/presentations/Speakers Bureau from Biosense Webster, Inc, and Boston Scientific. Dr Hussein has received steering committee funding from Biosense Webster, Inc. Dr Delaughter has received consulting fees and advisory board payments from Biosense Webster, Inc. Dr Natale has received consulting fees from Abbott, Baylis, Biosense Webster, Inc, Boston Scientific, Biotronik, and Medtronic. Dr Dukkipati has received grants from Biosense Webster, Inc. Dr Oza has received consulting fees from Biosense Webster, Inc and Atricure. Dr Daoud has received consulting fees from Biosense Webster, Inc, Medtronic, and S4 Medical; has received payments or honoraria for lectures/presentations/Speakers Bureau from ABIM, Western AF, and JACC: Clinical Electrophysiology; has patents planned, issued, or pending; has a leadership role in S4 Medical; and has stock/stock options from S4 Medical. Dr Di Biase has received consulting fees from Biosense Webster, Inc, Stereoataxis, and Rhythm Management; and has received speaker honoraria/travel from Biosense Webster, Inc, St Jude Medical (now Abbott), Boston Scientific, Medtronic, Biotronik, Atricure, Baylis, and Zoll. Dr Mansour has received grants from Biosense Webster, Inc, and Boston Scientific; has received consulting fees from Biosense Webster, Inc, Boston Scientific, Philips, and Medtronic; has received support for attending meetings/travel from Biosense Webster, Inc, and Boston Scientific; and has stock/stock options from New Pace Limited and EPD Solutions. Dr Valderrabano has received consulting fees from Baylis and Circa; and has received payments or honoraria for lectures/presentations/speakers’ bureaus from Biosense Webster, Inc. Dr Ellenbogen has received grants, consulting fees, and payment for lectures and advisory board from Biosense Webster, Inc, and has leadership positions at the American College of Cardiology and Heart Rhythm Society. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

The atrial appendage (LAA) is a well-established source of cardioembolism in patients with atrial fibrillation. Therefore, research involving the LAA has largely focused on its thrombogenic attribute and the utility of its exclusion in stroke prevention. However, recent studies have highlighted several novel functions of the LAA that may have important therapeutic implications. In this paper, we provide a concise overview of the LAA anatomy and summarize the emerging data on its nonthrombogenic roles., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Electrical isolation of pulmonary veins (PVI) is a cornerstone for atrial fibrillation (AF) ablation. The overall effect of AF ablation, and especially lesions beyond PVI, on left atrial (LA) function is currently poorly understood. Our aim was to determine if LA function is different in patients after extensive LA ablation compared to PVI only. We performed non-inferiority analysis of LA function after PVI with additional nonpulmonary vein ablation lesions in LA (PVI+) and PVI alone., Methods: We studied 68 patients consecutive patients who underwent AF ablation and who had complete transthoracic echocardiogram (TTE) within 12 months before AF ablation and 1-12 months after the procedure. Patients were stratified into two groups: PVI only and PVI+. Primary outcome was change in LA reservoir strain (LASr). Noninferiority margin was defined at 6%., Results: The PVI only group had a higher proportion of patients with paroxysmal AF (70% vs. 30%). The PVI+ group was observed to have a slightly higher increase in LASr compared to PVI alone (5.0% vs. 4.3%, p < .01 for noninferiority). LASr noninferiority was confirmed when adjusted for age, sex, coronary artery disease, hyperlipidemia, and AF type, rhythm at preprocedure TTE in a multivariable linear regression model, 90% CI (-5.46 to 2.04), p < .01., Conclusion: LA functional improvement evaluated by LASr was noninferior after PVI with additional LA ablation lesions compared to PVI alone. These findings were confirmed when adjusted for confounding clinical variables, suggesting that more extensive ablation does not negatively affect LA function., (© 2022 Wiley Periodicals LLC.)

Introduction: Atrial fibrillation (AF) and premature ventricular complexes (PVC) are common arrhythmias. We aimed to investigate AF prevalence in patients with PVC and its impact on PVC ablation outcomes., Methods: Consecutive patients undergoing PVC ablation at a single institution between 2016 and 2019 were included and prospectively followed for 2 years. Patients with severe valvular heart disease, hyperthyroidism, malignancy, alcohol use disorder and advanced renal/hepatic diseases were excluded. Twelve-lead electrocardiograms were used to diagnose AF and assess PVC morphology. All PVCs were targeted for ablation using 4-mm irrigated-tip catheters at standardized radiofrequency power guided by 3-D mapping and intracardiac echocardiography. Patients were followed with remote monitoring, device interrogations and office visits every 6 months for 2 years. Detection of any PVCs in follow-up was considered as recurrence., Results: A total of 394 patients underwent PVC ablation and 96 (24%) had concurrent AF. Patients with PVC and AF were significantly older (68.2 ± 10.8 vs. 58.3 ± 15.8 years, p < .001), had lower LV ejection fraction (43.3 ± 13.3% vs. 49.6 ± 12.4%, p < .001), higher CHA 2 DS 2 -VASc (2.8 ± 1.3 vs. 2.0 ± 1.3, p < .001) than those without. PVCs with ≥2 morphologies were detected in 60.4% and 13.7% patients with vs without AF (p < .001). At 2-year follow-up, PVC recurrence rate was significantly higher in patients with vs without AF (17.7% vs. 9.4%, p = .02)., Conclusion: AF was documented in 1/4 of patients undergoing PVC ablation and was associated with lower procedural success at long-term follow-up. This was likely attributed to older age, worse LV function and higher prevalence of multiple PVC morphologies in patients with concurrent AF., (© 2022 Wiley Periodicals LLC.)

Competing Interests: Funding Support and Author Disclosures Dr. Natale has served as a consultant for Abbott, Biosense Webster, Inc., Biotronik, Boston Scientific, Baylis, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Introduction: Increasing evidence has suggested improved outcomes in atrial fibrillation (AF) patients with heart failure (HF) undergoing catheter ablation (CA) as compared to medical therapy. We sought to investigate the benefit of CA on outcomes of patients with AF and HF as compared to medical therapy., Methods and Results: A systematic review of PubMed, Embase, and Cochrane Central Register of Clinical Trials was performed for clinical studies evaluating the benefit of CA for patients with AF and HF. Primary endpoint was all-cause mortality. Secondary endpoints included atrial-arrhythmia recurrence and improvement in left ventricular ejection fraction (LVEF). Eight randomized controlled trials were included with a total of 2121 patients (mean age: 65 ± 5 years; 72% male). Mean follow-up duration was 32.9 ± 14.5 months. All-cause mortality in patients who underwent CA was significantly lower than in the medical treatment group (8.8% vs. 13.5%, RR 0.65, 95% confidence interval [CI] 0.51-0.83, p = .0005). A 35% relative risk reduction and 4.7% absolute risk reduction in all-cause mortality was observed with CA. Rates of all-atrial arrhythmia recurrence were significantly lower in the CA group (39.9% vs. 69.6%, RR: 0.55, 95% CI: 0.40-0.76, p = .0003). Improvement in LVEF was significantly higher in patients undergoing CA (+9.4 ± 7.6%) as compared to conventional treatment (+3.3 ± 8%) (mean difference 6.2, 95% CI: 3.6-8.8, p < .00001)., Conclusion: CA for AF in patients with HF decreases all-cause mortality, improves all-atrial arrhythmia recurrence rate and LVEF when compared to medical management. CA should be considered the treatment of choice to improve survival in this select group of patients. Nonetheless, the benefit of CA in patients with severely reduced ejection fraction and New York Heart Association class IV HF has not been clearly elucidated., (© 2022 Wiley Periodicals LLC.)

Background: VISITAG SURPOINT (VS)-guided ablation of paroxysmal atrial fibrillation has demonstrated good short- and long-term success rates with low rates of complications in recent, predominantly European, studies. However, there is a lack of multicenter data from the United States., Objectives: This U.S. study evaluated the safety and effectiveness of VS ablation using a contact force-sensing catheter for the treatment of drug-refractory symptomatic paroxysmal atrial fibrillation., Methods: The prospective, nonrandomized VS postapproval study was conducted at 32 U.S. sites. Ablation consisted of pulmonary vein isolation with recommended VS index targets (anterior, roof, or ridge: 550; posterior or inferior: 380). Additional non-pulmonary vein triggers were ablated at the investigators' discretion. Subjects were followed for 12 months, including a 3-month blanking period. The primary safety endpoint was the primary adverse event rate up to 7 days postablation. The primary effectiveness endpoint was 12-month freedom from atrial tachyarrhythmia recurrence and an additional set of failure modes based on stringent monitoring (weekly transtelephonic monitoring [TTM] [day 91 through month 5], monthly TTM [months 6 to 12], and any symptomatic cardiac episode using TTM, plus electrocardiogram [at discharge, 1 month, 3 months, 6 months, and 12 months] with 24-hour Holter monitoring [12 months])., Results: Of 283 patients enrolled, 261 had the catheter inserted and underwent ablation (safety cohort); 246 met all eligibility criteria (effectiveness cohort). Mean fluoroscopy time was 2.2 minutes. Mean amount of catheter-delivered fluid was 671 mL; only 18.0% of patients utilized a Foley catheter. Primary safety and effectiveness endpoints were met. The raw primary adverse event rate was 4.3% (14 events, n = 11). At 12 months, the Kaplan-Meier estimate of freedom from primary effectiveness failure was 76.4%; estimates of 12-month freedom from documented atrial fibrillation, atrial tachycardia, or atrial flutter recurrence were 81.5% and 92.7% per stringent monitoring and standard-of-care monitoring (excluding TTM), respectively. The first-pass isolation rate was 83.1%, represented by no acute reconnection after the 30-minute waiting period. Freedom from repeat ablation at 12 months was 94.0%., Conclusions: The VS postapproval study confirms reproducibility of clinical safety and effectiveness of the standardized VS paroxysmal atrial fibrillation ablation workflow with &gt;80% 12-month freedom from atrial tachyarrhythmia recurrence and first-pass isolation rate of 83.1%. Procedures were performed with minimal fluoroscopy. (Evaluation of VISITAG SURPOINT™ Module With External Processing Unit [EPU]; NCT03624881)., Competing Interests: Funding Support and Author Disclosures This study was funded by Biosense Webster, Inc. Dr Di Biase has received consulting fees from Biosense Webster, Inc., Stereotaxis, and Rhythm Management; and has received speaker honoraria/travel compensation from Biosense Webster, Inc., St. Jude Medical (now Abbott), Boston Scientific, Medtronic, Biotronik, AtriCure, Baylis, and Zoll. Dr Melby has received consulting fees and speaker honoraria/travel compensation from Biosense Webster, Inc. Dr Natale has received consulting fees from Abbott, Baylis, Biosense Webster, Inc., Biotronik, Boston Scientific, and Medtronic. Dr Manyam has received consulting fees from Abbott and Janssen Pharmaceuticals. Dr Athill has received consulting fees from Biosense Webster, Inc., Abbott, and Boston Scientific; and has received speaker honoraria/travel compensation from Zoll and Janssen Pharmaceuticals. Dr Delaughter has received consulting fees from Biosense Webster, Inc. Drs Patel and McElderry, Jr., have received speaker honoraria/travel compensation from Biosense Webster, Inc. Dr Arkles has received speaker honoraria/travel compensation from Varian and Abbott. Dr Osorio has received consulting fees from Biosense Webster, Inc., Boston Scientific, and Medtronic; has received speaker honoraria/travel compensation from Biosense Webster, Inc., and Boston Scientific; and has received grants/contracts from Biosense Webster, Inc., and Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Catheter ablation (CA) has become the mainstay therapy for the maintenance of sinus rhythm in patients with atrial fibrillation (AF), with pulmonary vein isolation (PVI) the most frequently used treatment strategy. Although several energy sources have been tested (including radiofrequency, cryothermal and laser), these are not devoid of safety issues and in many instances effectiveness is dependent on operator experience. Pulsed field ablation (PFA) is a novel energy source by which high-voltage electric pulses are used to create pores in the cellular membrane (i.e., electroporation), leading to cellular death. The amount of energy required to produce irreversible electroporation is highly tissue dependent. In consequence, a tailored protocol in which specific targeting of the atrial myocardium is achieved while sparing adjacent tissues is theoretically feasible, increasing the safety of the procedure. While large scale clinical trials are lacking, current clinical evidence has demonstrated significant efficacy in achieving durable PVI without ablation related adverse events., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Coronary artery calcium (CAC) and epicardial adipose tissue (EAT) can predict AF in the general population. We aimed to determine if CAC and EAT measured by computed tomographic (CT) scanning can predict new-onset AF in patients admitted with COVID-19 disease., Methods: We performed a retrospective, post hoc analysis of all patients admitted to Montefiore Medical Center with a confirmed COVID-19 diagnosis from March 1st to June 23rd, 2020, who had a non-contrast CT of the chest within 5 years prior to admission. We determined ordinal CAC scores and quantified the EAT volume and examined their relationship with inpatient mortality., Results: A total of 379 patients were analyzed. There were 16 events of new-onset AF (4.22%). Patients who developed AF during the index admission were more likely to be male (75 vs 47%, p < 0.001) and had higher EAT (129.5 [76.3-197.3] vs 91.0 [60.0-129.0] ml, p = 0.049). There were no differences on age (68 [56-71] vs 68 [58-76] years; p = 0.712), BMI (28.5 [25.3-30.8] vs 26.9 [23.1-31.8] kg/m 2 ; p = 0.283), ordinal CAC score (3 [1-6] vs 2 [0-4]; p = 0.482), or prevalence of diabetes (56.3 vs 60.1%; p = 0.761), hypertension (75.0 vs 87.3%, p = 0.153), or coronary artery disease (50.0 vs 39.4%, p = 0.396). Patients with new-onset AF had worse clinical outcomes (death/intubation/vasopressors) (87.5 vs 44.1%; p = 0.001)., Conclusion: Increased EAT measured by non-contrast chest CT identifies patients hospitalized with COVID-19 at higher risk of developing new-onset AF. Patients with new-onset AF have worse clinical outcomes., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Pulsed-field ablation (PFA) is a tissue-selective, nonthermal cardiac ablation modality. A novel PFA ablation system consisted of a multichannel irreversible electroporation generator system and a multielectrode circular irreversible electroporation catheter has been developed for catheter ablation. To understand the progression and immediate impacts of PFA, this study evaluated the subchronic (7±3 day) and chronic (30±3 day) safety and performance of the novel PFA system when simulating pulmonary vein and superior vena cava isolation in a porcine beating heart model., Methods: Ten swine models were divided into subchronic (n=6) and chronic cohorts (n=4). Lesions were performed within the right and left atrium to conduct right pulmonary veins and superior vena cava isolations, in addition to creating stacked lesions in the left atrium roof and right atrium posterior wall., Results: Acute pulmonary vein and superior vena cava isolation were achieved in 10 out of 10 swine and demonstrated 100% lesion durability in both cohorts, including sustained elimination of electrical activity at the left atrium roof and right atrium posterior wall. Histology demonstrated that all the cardiac sites ablated showed discrete zones of loss of myocardial fibers or smooth muscle cells with preservation of the tissue architecture with resultant fibrocellular replacement, neovascularization, and neocollagen deposition. Mineralization findings were present in association with residual necrotic muscle fibers. Only in 7 days group, areas of mineralization were frequently associated with inflammation. There were no treatment-related changes in other tissues, including complete sparing of the phrenic nerve., Conclusions: Pulsed-field ablation for pulmonary vein and superior vena cava isolation with the novel PFA system was feasible, safe with myocardial-specific ablative effect. Durable lesions were observed at the target areas. with inflammation phenomena mainly documented at 7 days.

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.