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A 63-year-old man with hypertension was referred for catheter ablation of persistent atrial fibrillation. He was diagnosed with paroxysmal atrial fibrillation approximately 6 years prior. Over the previous 12 months, his atrial fibrillation had become persistent despite medication optimisation for rate control and elective cardioversion. Sinus rhythm was restored briefly. The decision was made to pursue catheter ablation and isolation of the pulmonary veins. On anaesthetic induction, the patient suffered from a hypertensive crisis. The procedure was aborted, and the patient was admitted to hospital for investigations of secondary hypertension. Ultimately, the patient was diagnosed with bilateral pheochromocytomas. This case outlines the diagnostic challenges and cardiac comorbidities associated with bilateral pheochromocytomas.

Background Burden of atrial fibrillation (AF), as a continuous measure, is an emerging alternative classification often assumed to increase linearly with progression of disease. Yet there are no descriptions of AF burden distributions across populations. Methods We examined patterns of AF burden (% time in AF) across 3 different cohorts: outpatients with AF undergoing Holter monitoring in a national registry (ORBIT-AF II), routine outpatients undergoing Holter monitoring in a tertiary healthcare system (UHealth), and patients >=65 years with cardiac implantable electronic devices (Merlin.netTM linked to Medicare). Results We included 2,058 ORBIT-AF II patients, 4,537 UHealth patients, and 39,710 from Merlin.netTM. Mean age ranged from 56 to 77 years, sex ranged from 40% to 61% male, and mean CHA2DS2-VASc scores ranged from 2.2 to 4.9. Across all cohorts, AF burden demonstrated skewed frequency towards the extremes, with the vast majority of patients having either very low or very high AF burden. This bimodal distribution was consistent across cohorts, across clinically-documented AF types (paroxysmal vs. persistent), patients with or without a known AF diagnosis, and among patients with different types of cardiac implantable electronic devices. Conclusions Across 3 broad, diverse cohorts with continuous monitoring, distribution of AF burden was consistently skewed towards the extremes without an even, linear distribution or progression. As AF burden is increasingly recognized as a descriptor and potential risk-stratifier, these findings have important implications for future research and patient care.

BACKGROUND Left atrial (LA) global strain has been studied as an early marker of LA dysfunction, followed by LA dilatation. Recently, a novel dedicated software for LA 3-dimensional speckle tracking echocardiography (LA-3DSTE) has allowed us to assess anatomy-based six-segmental LA deformation. This study aimed to assess the accuracy of LA-3DSTE software in measuring LA volume and to reveal the characteristics of regional LA reservoir strain. METHODS Fifty patients with paroxysmal atrial fibrillation who underwent computed tomography (CT) and 3D-STE were enrolled. The LA volumes obtained by 3D-STE and CT were compared, and regional LA strain was analyzed. Six LA segments (anterior, septal, inferior, lateral, roof, and posterior) were determined on the basis of LA anatomy. RESULTS In 50 patients (mean age, 64 years; 62% male), the 3D-STE-derived LA volume index (LAVI) showed good correlation with the CT-derived index, (r = 0.78, p < 0.001) with an underestimate bias of 10.5 ± 11.0 ml/m2 (p < 0.001). The lateral LA strain was negatively correlated with LAVI and emptying fraction, while the anterior and septal strains were not. In the 1st quantile LA volume group, the segmental LA strain was heterogeneous, that is, the lateral and inferior strains were greater than the anterior strain. While in the 3rd quantile LA volume group, the lateral and inferior strains were decreased, and there was no regional difference. CONCLUSION LA volume obtained by 3D-STE and CT showed a good correlation. LA segmental analysis by 3D-STE enables early identification of how LA dysfunction affects lateral and inferior LA strains, consistent with anatomical features.

Background Recent randomized controlled trials (RCTs) suggest that ablation is superior to antiarrhythmic drugs (AADs) as an initial therapy for paroxysmal atrial fibrillation (pAF) to prevent arrhythmia recurrences. We performed an updated meta‐analysis of RCTs, to include recent data from cryoballoon‐based ablation and to compare arrhythmia‐free survival and adverse events between ablation and AADs. Methods We searched MEDLINE and EMBASE from inception to December 2020. We included RCT comparing patients with pAF undergoing ablation or receiving AADs as an initial therapy. We combined data using the random‐effects model to calculate hazards ratio (HR) for arrhythmia‐free survival and odds ratio (OR) for adverse events. Results Five studies from 2005 to 2020 involving 985 patients were included (495 patients and 490 patients underwent ablation and medication as initial therapy, respectively). Patients who underwent ablation had higher freedom from atrial tachyarrhythmias (ATs) during the 12‐24 months follow‐up period (pooled HR = 0.48, 95% CI: 0.40‐0.59, P, We performed meta‐analysis of the most recent randomized control trials evaluating atrial fibrillation ablation as the first line therapy

Purpose A new type of visualized steerable sheath (Vizigo sheath; Biosense Webster Inc., Irvine, CA, USA) has been employed in clinical treatment. This study aimed to compare the effectiveness and safety of the Vizigo sheath to a fixed sheath (Swartz sheath; St. Jude Inc., St. Paul, MN, USA) for catheter ablation of paroxysmal atrial fibrillation (PAF). Methods We analyzed the procedural time, fluoroscopy time, contact force (CF), and initial pulmonary vein isolation (PVI) rate. After 6 months of follow-up, the success rate of ablation between the two groups was compared. Results Compared to the Swartz sheath, using the Vizigo sheath can significantly reduce the total procedural time and fluoroscopy time and increase the overall average CF, especially in the anterior left pulmonary vein (LPV), superior LPV, posterior right pulmonary vein (RPV), and superior RPV. The proportion of CF within a reasonable range in the Vizigo group was significantly higher than that in the Swartz group, especially in the anterior LPV, posterior RPV, and superior RPV. Besides, the left, right, and bilateral initial PVI rates in the Vizigo group were significantly higher. Conclusions The visualized steerable sheath for PAF catheter ablation not only reduced radiation exposure but also significantly improved CF and initial PVI rate, all of which indicated an increased rate of successful ablation.

Background Over the last 20 years various techniques have been developed striving for safer and more durable pulmonary vein isolation (PVI). The three most commonly used tools are pulmonary vein ablation catheter (PVAC) and cryoballoon (‘single-shot’ techniques), and point-by-point (PBP) radiofrequency ablation using 3D electroanatomical mapping (EAM). Objective Evaluate the safety and efficacy of the different techniques in an unselected population undergoing de-novo ablation for persistent or paroxysmal atrial fibrillation (AF) at Royal Papworth Hospital (RPH). Method Retrospective, single-centre study of consecutive AF ablations at RPH between March 2017 and April 2018. Demographic, procedural and outcome data were analysed. Results Over the study period 329 first-time PVI procedures were performed. 37.4% were performed using PBP, 39.8% using cryoballoon and 22.8% using PVAC. There was no significant difference in age or sex between different ablation technique groups. 238 procedures were performed for paroxysmal AF and 91 for persistent AF. A higher proportion of the persistent cases were performed using point-by-point techniques compared to paroxysmal cases (58.2% vs 29.0%, p, Highlights • The performance of PVAC, cryoballoon and point-by-point ablation in AF ablation has never been compared head-to-head-to-head. • Analysis of 329 PVI procedures showed no difference in symptomatic AF recurrence or safety outcomes between techniques. • Point-by-point procedures were longer.

Purpose We aimed to investigate whether the sequence of wide circumferential pulmonary vein isolation (PVI) ablation had an effect on the acute reconnection or long-term effectiveness in patients with paroxysmal atrial fibrillation (AF). Methods One hundred consecutive paroxysmal AF patients, who were scheduled to accept PVI, were enrolled and randomized into two groups: (1) optimized group. Lesions were first applied to the anterior/posterior carina and the ridge between the left atrial (LA) appendage and the left pulmonary vein (PV). Then both circles were closed with continuous lesions. (2) Sequential group-continuous circular lesions were created counter-clockwise and started from the site of 6 o'clock. The primary endpoint was the freedom from non-blanking period recurrence of any atrial tachyarrhythmias lasting for 30 s or longer during the 1-year follow-up period after a single procedure. The secondary endpoint included safety endpoints, LA dwelling time, and fluoroscopy time/dose. Results Forty-nine patients in the optimized group and 48 patients in the sequential group were available for analysis. There was no difference between the AF-free rate of the optimized group and the sequential group (75.5% vs. 72.9%, p = 0.7715). Cox regression analysis found that acute reconnection had the potential to predict long-term recurrence at 1 year (Risk ratio 2.175, p = 0.0818). Both groups had similar safety endpoints, LA dwelling time, and fluoroscopy time/dose. Conclusions Adjusting the ablation sequence of PVI by ablating the anterior/posterior carina and the ridge between the left PV and the LA appendage first did not improve 1-year AF-free rate for paroxysmal AF.

Aim. To study the incidence and possible risk factors for atrial fibrillation (AF) in the early postoperative period after transapical implantation of the first Russian aortic valve (TAP-AVI).Methods. The study included 118 patients after successful TAP-AVI. Patients with open aortic valve replacement due to dislocation of the prosthesis were excluded, as well as subjects with permanent AF and who died in the early postoperative period. The mean age of the patients was 71.1±4.9 years, body mass index 31.1±5.9 kg/m2 , males - 39.8%, hypertension was present in 93.2%, diabetes mellitus (DM) - in 27.9%, paroxysmal AF - in 12.7%, coronary artery disease (CAD) was in 56.7%, 8.4% were smokers. The median follow-up time corresponded to the hospital stay - 9.5 days. To identify cardiac arrhythmias, regular daily ECG recording in 12 leads was initiated from the first day after TAP-AVI. In the presence of palpitations, 24-hour ECG monitoring was performed. Indicators such as age, male gender, DM, history of AF, interatrial block before surgery, CAD, and echocardiographic parameters were studied as possible predictors of AF development in the early postoperative period after TAP-AVI. There were no significant differences in the baseline parameters in patients with AF paroxysms and sinus rhythm.Results. In the early postoperative period, AF was encountered in 46 (39%) of patients. New-onset AF occurred in 38 (32.2%) patients. No cerebrovascular event occurred in patients with post-surgery AF. The only statistically significant risk factor for AF in the postoperative period was CAD (OR 5.756; 95% CI 1.009-8.132; p = 0.048).Conclusion. In the early postoperative period, the only significant predictor of AF was the presence of documented CAD.

Aim. To analyze heart rate variability of patients with paroxysmal atrial fibrillation and identify electrophysiological phenotypes of the disease by using methods of exploratory analysis of twenty-four-hour electrocardiographic (Holter) recordings. Methods. 64 electrocardiogram recordings of patients with paroxysmal atrial fibrillation were selected from the open Long-Term Atrial Fibrillation Database (repository PhysioNet). 52 indices of heart rhythm variability were calculated for each recording, including new heart rate fragmentation and asymmetry indices proposed in the last 5 years. Data analysis was carried out with machine learning methods: dimensionality reduction with principal component analysis, hierarchical clustering and outlier detection. Feature correlation was checked by the Pearson criterion, the selected patients subgroups were confirmed by using MannWhitney and Student's tests. Results. For the vast majority of patients with paroxysmal atrial fibrillation, heart rate variability can be described by five parameters. Each of these parameters captures a distinct approach in heart rate variability classification: dispersion characteristics of interbeat intervals, frequency characteristics of interbeat intervals, measurements of heart rate fragmentation, indices based on heart rate asymmetry, mean and median of interbeat intervals. Two large phenotypes of the disease were derived based on these parameters: the first phenotype is a vagotonic profile with a significant increase of linear parasympathetic indices and paroxysmal atrial fibrillation lasting longer than 4.5 hours; the second phenotype with increased sympathetic indices, low parasympathetic indices and paroxysms lasting up to 4.5 hours. Conclusion. Our findings indicate the potential of nonlinear analysis in the study of heart rate variability and demonstrate the feasibility of further integration of nonlinear indices for arrhythmia phenotyping.

Paroxysmal atrial fibrillation (PAF) is the initial stage of atrial fibrillation, one of the most common arrhythmia types. PAF worsens with time and affects the patient's life quality negatively. In this study, we aimed to diagnose PAF early, so patients can start taking precautions before this disease gets worse. We used the atrial fibrillation prediction database, an open data from Physionet and constructed our approach using convolutional neural networks. Heart rate variability (HRV) features are calculated from time-domain measures, frequency-domain measures using power spectral density estimations (fast Fourier transform, Lomb-Scargle, and Welch periodogram), time-frequency-domain measures using wavelet transform, and nonlinear Poincare plot measures. We also normalized these features using min-max normalization and z-score normalization methods. In addition, we also applied alternatively the heart rate normalization (HRN), which gave promising results in a few HRV-based research, before calculating these features. Thus, HRV data, HRN data, and HRV features extracted from six different combinations of these normalizations, in addition to no normalization cases, were applied to the convolutional neural networks classifier. We tuned the classifiers using 90% of samples and tested the classifiers' performances using 10% of data. The proposed approach resulted in 95.92% accuracy, 100% precision, 91.84% recall, and 95.74% f1-score in HRV with z-score feature normalization. When the heart rate normalization was also applied, the proposed approach reached 100% accuracy, 100% precision, 100% recall, and 100% f1-score in HRV with z-score feature normalization. The proposed method with heart rate normalization and z-score normalization methods resulted in better classification performance than similar studies in the literature. In addition, although deep learning models offer no use of separate feature extraction processes, this study reveals that using HRV-specific feature extraction techniques may improve the performance of deep learning algorithms in HRV-based studies. Comparing the existing studies, we concluded that our approach provides a much better tool to diagnose PAF patients. WOS:000709712800008 2-s2.0-85117118593

Background Long-term outcomes of suppressing paroxysmal atrial fibrillation (PAF) with additive ganglionated plexus (GP) ablation (GPA) remains unknown. Objectives The aim of the study is to assess potential role of additional GPA for PAF suppression. Methods This study consisted of 225 patients; 68 (group A: 58 male, aged 60 ± 11 years) underwent pulmonary vein isolation (PVI) alone and 157 (group B: 137 male, aged 61 ± 11 years) GPA followed by PVI. GPA was performed based on the high-density mapping with high-frequency stimulation (HFS) delivered to left atrial (LA) major GP. The latter 85 group B patients (54%) underwent ablation to a posteromedial area within superior vena cava as a part of dorsal right atrial GP (SVC-Ao GP). Results In group B, HFS was applied to 126 ± 32 sites, with a median of 47 GP sites (40.0%) being ablated. In patients undergoing an SVC-Ao GPA, HFS and the SVC-Ao GPA were applied at a median of 15 and 4 sites (29.4%), respectively. The PVI with a GPA provided higher PAF suppression than a PVI alone during more than 4 years of follow-up (56.7% vs 38.2%, odds ratio: 0.42, 95% confidence interval: 0.23–0.76, P < .05), but the SVC-Ao GPA did not provide further suppressive effects. Multivariate analyses revealed that tachycardia-bradycardia syndrome and non-PV foci were independent predictors of PAF recurrence after PVI with a GPA (P < .01). Conclusion GPA to LA major GP by high-density mapping provides long-term benefits for PAF suppression over 4 years of follow-up, but the effect of an empiric SVC-Ao GPA could not be appreciated, suggesting little effect on suppressing non-PV foci.

A case of successful treatment for syncopal episodes caused by intermittent atrioventricular block in a patient with paroxysmal atrial fibrillation/atrial flutter using cardioneuroablation is presented.

This work is devoted to the dynamic study of heart rate variability indicators for one year in patients with paroxysmal atrial fibrillation treated with antiarrhythmic drugs metoprolol and cordarone. The study found that patients treated with metoprolol monotherapy had a weakening of parasympathetic effects on the heart, due to a decrease in Mean by 12.9%, Mo by 13%, Amo by 29.4%, SDNN by 28.3% compared to the group of healthy individuals, but they differed in stable indicators of heart rate variability and 33% retained sinus rhythm during the year. With cordarone monotherapy, there was a curative effect of sympathetic and parasympathetic effects on the heart, as indicated by an increase in: Mean by 15.9%, Mo by 15.9%, IVR by 95.5%, Amo by 41.1% and a decrease in SDNN by 37.5%, compared with the group of healthy individuals at the initial stage. A year later, a negative dynamics was revealed - the predominance of sympathetic influences on the heart compared to the groups of healthy individuals and the control due to an increase in: IVR by 363.3% and 238.5%; VPR by 116.7% and 106%; Amo by 111.2% and 72.9; IN by 304% and 246.8%; PAPR by 92% and 79.1%, respectively. During the year, 39% of patients left the study due to the replacement of antiarrhythmic therapy and 16.5% due to the development of a permanent form of atrial fibrillation. In the remaining patients in the study, in comparison with their initial data, there was a predominance of sympathetic effects on the heart due to an increase in IVR by 137%. In combination therapy with metoprolol and cordarone, there were no significant changes in heart rate variability compared to the initial ones. Initially, there was a decrease in overall heart rate variability due to a decrease in SDNN by 28.4% and a decrease in parasympathetic effects on the heart due to an increase in Amo by 45.2% and a decrease in Delta X by 32.9% compared to the group of healthy individuals. After a year, 40% left the study due to the replacement of antiarrhythmic therapy and 30% due to the development of a permanent form of atrial fibrillation. During dynamic observation of patients, it was found that the following indicators have the most important prognostic value in the development of atrial fibrillation: SDNN, Delta X and RMSSD. Therefore, it is very important to register an ECG with the measurement of these indicators at least once every 3 months for timely correction of treatment.

Aims To determine if adapting the ablation index (AI) to the left atrial wall thickness (LAWT), which is a determinant of lesion transmurality, is feasible, effective, and safe during paroxysmal atrial fibrillation (PAF) ablation. Methods and results Consecutive patients referred for PAF first ablation. Left atrial wall thickness three-dimensional maps were obtained from multidetector computed tomography and integrated into the CARTO navigation system. Left atrial wall thickness was categorized into 1 mm layers and AI was titrated to the LAWT. The ablation line was personalized to avoid thicker regions. Primary endpoints were acute efficacy and safety, and freedom from atrial fibrillation (AF) recurrences. Follow-up (FU) was scheduled at 1, 3, 6, and every 6 months thereafter. Ninety patients [60 (67%) male, age 58 ± 13 years] were included. Mean LAWT was 1.25 ± 0.62 mm. Mean AI was 366 ± 26 on the right pulmonary veins with a first-pass isolation in 84 (93%) patients and 380 ± 42 on the left pulmonary veins with first-pass in 87 (97%). Procedure time was 59 min (49–66); radiofrequency (RF) time 14 min (12.5–16); and fluoroscopy time 0.7 min (0.5–1.4). No major complication occurred. Eighty-four out of 90 (93.3%) patients were free of recurrence after a mean FU of 16 ± 4 months. Conclusion Personalized AF ablation, adapting the AI to LAWT allowed pulmonary vein isolation with low RF delivery, fluoroscopy, and procedure time while obtaining a high rate of first-pass isolation, in this patient population. Freedom from AF recurrences was as high as in more demanding ablation protocols. A multicentre trial is ongoing to evaluate reproducibility of these results.

The relationship between height and incident atrial fibrillation (AF) has recently been demonstrated. We aimed to evaluate the impact of height on outcomes of ablation in patients with drug-refractory symptomatic paroxysmal AF (PAF). A total of 689 patients (470 males; age, 53.0 ± 11.7 years) with symptomatic paroxysmal AF receiving index catheter ablation (CA) between 2003 and 2013 were enrolled in this study. The baseline characteristics, ablation, and follow-up results were evaluated. The patients were categorized according to the quartiles of height for each sex. Patients in the lower quartiles of height had a lower incidence of AF recurrence (log-rank p = 0.022). Height in female patients was strongly associated with AF recurrence (p = 0.027) after an index ablation in the 6.33 ± 4.32 years of follow-up. Female patients > 159 cm in height had a higher likelihood of AF recurrence after index CA (HR = 2.01, 95% CI: 1.24–3.25, p = 0.005) than that in those below this height. In computed tomography (CT) scan, the superoinferior diameter of the left atrium (LA) correlated with body height in females, but not in male patients. Height is associated with AF recurrence after the index CA of PAF in female patients. In Asian populations, women above height 159 cm are twice as likely to have AF recurrence post-ablation as shorter women.

Evaluation of the efficacy and safety of the modified refralon administration protocol for the relief of paroxysmal atrial fibrillation (AF).The study included 39 patients (19 men, mean age 6312.8 years). All patients, after excluding contraindications in the intensive care unit, were injected intravenously with refralon at an initial dose of 5 mg/kg. If AF was preserved and there were no contraindications, after 15 min, repeated administration was performed at a dose of 5 mg/kg (total dose of 10 mg/kg). After another 15 min, while maintaining AF and the absence of contraindications, the third injection of the drug was performed at a dose of 10 mg/kg (total dose of 20 mg/kg). In the absence of relief and the absence of contraindications, another injection of refralon at a dose of 10 mg/kg was performed after another 15 min (in this case, the maximum total dose of 30 mg/kg was reached). After each injected bolus and before the introduction of the next one, the ECG parameters and the general condition of the patient were assessed. The patient was monitored for 24 hours to exclude the arrhythmogenic effect and other possible adverse events.Restoration of sinus rhythm (SR) was noted in 37 patients out of 39 (95%). Of these, 19 people (48.7%) had SR recovery after the administration of a minimum dose of refralone of 5 mg/kg. The effectiveness of the total dose of 10 mg/kg was 76.9%, the dose of 20 mg/kg was 89.7%, and the dose of 30 mg/kg was 95%. Only two patients did not recover HR after administration of the maximum dose of refralon 30 mg/kg. Pathological prolongation of the QTc interval (500 ms) was recorded in 5% of patients. Not a single case of ventricular arrhythmogenic action (induction of Torsade de pointes) has been reported. Bradyarrhythmias (pauses, bradycardia) were registered in 13% of cases, were of a transient nature.Refralon has a high efficiency of relief (95%) of paroxysmal AF, while in almost half of cases (48.7%), SR recovery is achieved using the minimum dose of refralon 5 mg/kg. Despite the prolongation of the QTc500 ms recorded in 5% of cases, none of the patients developed Torsade de pointes after administration of the drug.Цель. Оценка эффективности и безопасности применения модифицированного протокола введения Рефралона для купирования пароксизмальной формы фибрилляции предсердий (ФП). Материалы и методы. В исследование включены 39 больных (из них 19 мужчин, средний возраст 6312,8 года). Всем пациентам после исключения противопоказаний в условиях блока интенсивной терапии вводился внутривенно Рефралон в первоначальной дозе 5 мкг/кг. При сохранении ФП и отсутствии противопоказаний через 15 мин производили повторное введение в дозе 5 мкг/кг (суммарная доза 10 мкг/кг). Еще через 15 мин при сохранении ФП и отсутствии противопоказаний производили третье введение препарата в дозе 10 мкг/кг (суммарная доза 20 мкг/кг). При отсутствии купирования и противопоказаний еще через 15 мин производили еще одно введение Рефралона в дозе 10 мкг/кг (в этом случае достигалась максимальная суммарная доза 30 мкг/кг). После каждого введенного болюса и перед введением последующего проводилась оценка параметров электрокардиограммы и общего состояния пациента. Наблюдение за пациентом продолжалось в течение 24 ч для исключения аритмогенного эффекта и других возможных нежелательных явлений. Результаты. У 37 (95%) из 39 пациентов отмечено восстановление синусового ритма (СР). Из них у 19 (48,7%) человек восстановление СР произошло после введения минимальной дозы Рефралона 5 мкг/кг. Эффективность суммарной дозы 10 мкг/кг составила 76,9%, дозы 20 мкг/кг 89,7%, дозы 30 мкг/кг 95%. Лишь у 2 пациентов восстановления СР после введения максимальной дозы Рефралона 30 мкг/кг не произошло. Патологическое удлинение интервала QTc (500 мс) регистрировалось у 5% больных. Не зарегистрировано ни одного случая желудочкового аритмогенного действия (индукции Torsade de pointes). Брадиаритмии (паузы, брадикардия) зарегистрированы в 13% случаев и носили преходящий характер. Заключение. Рефралон обладает высокой эффективностью (95%) купирования пароксизмальной формы ФП, при этом почти в 1/2 (48,7%) случаев восстановление СР достигается при использовании минимальной дозы Рефралона 5 мкг/кг. Несмотря на зарегистрированное в 5% случаев удлинение интервала QTc (500 мс), ни у одного из больных после введения препарата не отмечалось развития Torsade de pointes.

The search for a less invasive and lower cost cryoballoon-based strategy for atrial fibrillation (AF) ablation has resulted in a simplified procedure that may be suitable for cryoballoon ablation (CBA). Here, we compared procedural characteristics and outcomes between conventional CBA and simple CBA. We enrolled 628 consecutive patients who underwent initial CBA for AF (age, 69 ± 12 years; female, 263 (42%); paroxysmal AF, 576 (92%); CHA2DS2-VASc score, 2.7 ± 1.6 points). Simple CBA was characterized by the minimal procedure required to isolate pulmonary veins, including the following: (1) CBA was performed without guidance from a 3-D mapping system; (2) a coronary sinus electrode and esophageal temperature probe were not used; (3) a waiting period after pulmonary vein isolation was not set; and AF induction by isoproterenol and atrial burst stimuli were not performed. Simple CBA was performed in 240 (38%) patients. Procedural time (49 ± 18 versus 85 ± 27 min, p

Background Atrial fibrillation (AF) is a highly prevalent arrhythmia, with substantial associated morbidity and mortality. Circumferential pulmonary vein ablation (CPVA) is an effective rhythm control strategy, however, recurrence is an important factor influencing treatment decisions. Hypothesis To develop a predictive model based on left atrial (LA) structure and function, and evaluate its efficiency in predicting the recurrence of AF after CPVA. Methods Patients with paroxysmal AF who underwent CPVA were enrolled in this study and randomly divided into a development set and a validation set. The clinical and echocardiographic data of each patient were collected. In the development set, a least absolute shrinkage and selection operator (LASSO) regression was used to establish a LA ultrasound feature. By combining that LA ultrasound feature with independent clinical risk factors, we established an echocardiographic model using multivariate logistic regression and plotted the corresponding nomogram. Results The LA ultrasound feature established by LASSO regression included nine echocardiographic indicators related to LA structure and function. It also exhibited good predictive ability in both the development set and the validation set (AUC:0.944, 95%CI: 0.910–0.978; AUC:0.878, 95%CI: 0.816–0.942). Logistic regression analysis indicated that LA ultrasound feature and AF duration were independent predictors for AF recurrence. The combined model including LA ultrasound feature and AF duration also showed good discriminability in both the development set (AUC: 0.950, 95% CI:0.914–0.985) and the validation set (AUC: 0.890, 95% CI: 0.831–0.949). The calibration curve showed good agreement between the predicted value and observed value. Conclusions Our model that is based on LA structure and function measured by echocardiography is a useful non‐invasive preoperative tool, which exhibits good accuracy in predicting the recurrence of AF after CPVA.

BACKGROUND The single procedure success rates of durable pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) varies between 80 and 90%. Ablation index, incorporating contact force, stability, time and power is a more profound parameter of significant lesion size and has been established. Equally important is a stringent contiguity of the lesion set. METHODS AND RESULTS A total number of 100 consecutive patients undergoing de-novo catheter ablation for paroxysmal atrial fibrillation (PAF) were analyzed between 2016 and 2019. In the first 50 patients (group A) PVI was performed using a surround flow, contact force catheter (Biosense Webster Thermocool STSF, Biosense Webster, USA) with a drag-and-ablate technique to encircle the PVs. In the following 50 patients (group B), PVI was performed using ablation index and a stringent lesion contiguity with an interlesion distance (ILD) of

Background Acute pulmonary vein reconnection (PVR) is associated with long procedure times and large radiofrequency (RF) energy delivery during pulmonary vein isolation (PVI). Although the efficacy of high‐power PVI (HP‐PVI) has been recently established, the determinants of acute PVR following HP‐PVI remain unclear. Methods We evaluated data on 62 patients with paroxysmal atrial fibrillation undergoing unipolar signal modification (USM)‐guided HP‐PVI. A 50‐W RF wave was applied for 3‐5 seconds after USM. In the segments adjacent to the esophagus (SAEs), the RF time was limited to 5 seconds. Each circle was subdivided into six regions (segments), and the possible predictors of acute PVR, including minimum contact force (CFmin), minimum force‐time integral (FTImin), minimum ablation index (AImin), minimum impedance drop (Imp‐min), and maximum inter‐lesion distance (ILDmax), were assessed in each segment. Results We investigated 1162 ablations in 744 segments (including 124 SAEs). Acute PVR was observed in 21 (17%) SAEs and 43 (7%) other segments (P = .001). The acute PVR segments were characterized by significantly lower CFmin, FTImin, AImin, and Imp‐min values in the segments other than the SAEs and larger ILDmax values in the SAEs. Furthermore, lower Imp‐min and larger ILDmax values independently predicted acute PVR in the segments other than the SAEs and SAEs (odds ratios 0.90 and 1.39 respectively). Acute PVR was not significantly associated with late atrial fibrillation recurrence. Conclusions Avoiding PVR remains a challenge in HP‐PVI cases, but it might be resolved by setting the optimal target impedance drop and lesion distance values., In high‐power pulmonary vein isolation, impedance drop has a superiority to predict in‐procedure gap as compared with ablation index.

Background Non-vitamin K antagonist oral anticoagulants (NOACs) are as effective and safe as warfarin for thromboembolic prevention and treatment. The efficacy of NOACs lacks evidence from large and randomized studies in patients with inherited severe thrombophilia, including protein S deficiency. Further, some concerns still exist regarding the relative efficacy of edoxaban in preventing arterial thromboembolism in patients with normal to high creatinine clearance (CrCl). We present a case of a rare complication of lead thrombus under standard-dose edoxaban in a patient with protein S deficiency and supernormal renal function. Case presentation A 65-year-old man experienced persistent chest tightness and a high level of D-dimer. Chest computed tomography (CT) showed a lead thrombus at the superior vena cava. He had a medical history including, paroxysmal atrial fibrillation (PAf), sick sinus syndrome after permanent pacemaker implantation, and transient ischemic attack. He received standard-dose edoxaban (60 mg daily) after PAf was diagnosed. His estimated CrCl was 98.6–102.1 mL/min. However, protein S deficiency (22.8%; normal range: 55–130%) was diagnosed. After switching to dabigatran (150 mg twice daily) for 3 months, the chest CT showed lead thrombus resolution and no symptoms were seen during the follow-up period. Conclusions This case was a rare complication of lead thrombus in a protein S deficient patient with normal renal function receiving standard-dose edoxaban. Edoxaban efficacy is uncertain in patients with protein S deficiency, and intracardiac devices also increase the risk of thromboembolic events.

Upper venous system anatomic variations may cause difficulties during cardiac pacemaker implantation. Persistent left superior vena cava (PLSVC) and absent right superior vena cava could be an arrhythmogenic source of atrial arrhythmias and cardiac conduction disease. We represent dual-chamber pacemaker implantation in a patient with a very rare upper venous system anomaly, paroxysmal atrial fibrillation, sick sinus syndrome, that cause unusual fluoroscopic image.

A 54-year-old man with paroxysmal atrial fibrillation underwent pulmonary vein (PV) isolation using a 28-mm second-generation cryoballoon catheter. Unexpected electrical superior vena cava (SVC) isolation during cryoballoon application to the right superior PV was observed in the first procedure. Thirteen-months after cryoballoon-based PV isolation, sustained SVC fibrillation was confirmed irrespective of sinus rhythm. Voltage mapping visualized a low voltage area around the SVC was close to that around the right superior PV. SVC isolation was obtained by cryoballoon application to the right superior PV and persisted for over a year.

Aims. 3D electroanatomical mapping combined with intracardiac echocardiography- (EAM-ICE-) guided transseptal puncture has been proven safe and effective during the radiofrequency catheter ablation (RFCA) procedure used to treat paroxysmal atrial fibrillation (PAF). In this study, we aimed to compare the curative effect and safety of RFCA via F (fluoroscopy) and zero-fluoroscopy transseptal puncture guided by EAM-ICE in patients with PAF. Methods and Results. A prospective study in which 110 patients with PAF were included and assigned to two groups was conducted. Fifty-five (50%) patients were enrolled in the EAM-ICE group, whereas the other 55 (50%) patients were enrolled in the F group. There were no significant differences in baseline characteristics between the two groups. The transseptal duration time was longer in the EAM-ICE group (19.8 ± 3.0 min vs. 8.6 ± 1.2 min, p ≤ 0.01 ); however, fluoroscopy was not used in the EAM-ICE group compared with the F group (0 mGy vs. 109.1 ± 57.9 mGy). Similarly, there was also no significant difference in the recurrence rate of atrial fibrillation between the EAM-ICE and F groups (25.5% vs. 18.2%, p = 0.356 ). Conclusion. RFCA via EAM-ICE-guided zero-fluoroscopy transseptal puncture in patients with PAF is safe and effective for long-term follow-up.

Background This study aimed to investigate the correlation between left atrial low‐voltage areas (LVAs) and an arrhythmogenic superior vena cava (SVC) and the impact on the efficacy of an empiric SVC isolation (SVCI) along with a pulmonary vein isolation (PVI) of non‐paroxysmal atrial fibrillation (non‐PAF) with or without LVAs. Methods We retrospectively enrolled 153 consecutive patients with non‐PAF who underwent a PVI alone (n = 51) or empiric PVI plus an SVCI (n = 102). Left atrial voltage maps were constructed during sinus rhythm to identify the LVAs (, The LVAs was associated with an arrhythmogenic SVC in non‐PAF patients. An SVCI compensated for an impaired outcome after PVI in non‐PAF patients with LVAs.

Background: Although atrial fibrillation (AF) is a well-known risk factor for embolic stroke in hypertrophic cardiomyopathy (HCM), there is a paucity of information derived from HCM patients who have experienced embolic stroke. Methods and Results: From 141 consecutive HCM patients who had been hospitalized between 2000 and 2018, the clinical characteristics and management of 86 patients with AF were analyzed retrospectively. The incidence of embolic stroke was 36% (n=31 patients). The median (interquartile range) age of embolic stroke was younger in male than female HCM patients (71 [64–80] vs. 83 [77–87] years, respectively; P=0.009). The prevalence of paroxysmal AF (74%) was significantly higher than that of chronic AF (26%) in 31 patients with embolic stroke (P=0.007). The CHADS2 score in patients with embolic stroke was not particularly useful in predicting the occurrence of embolic stroke. Conclusions: One-third of HCM patients with AF developed embolic stroke, and male HCM patients were younger at the time of the embolic stroke than female HCM patients. The prevalence of paroxysmal AF was significantly higher than that of chronic AF in patients with AF and embolic stroke. Early introduction of anticoagulation therapy is recommended at the first documentation of paroxysmal AF.

Semaphorin4D (Sema4D), a novel integral membrane glycoprotein, plays a role in atherosclerosis, angiogenesis and chronic inflammation. Elevated levels of sema4D were presented in myocardial infarction, heart failure and atrial fibrillation. Aim of the study was to investigate the relation between sema4D and recurrence after catheter ablation (CA) in paroxysmal AF.The present study included 161 paroxysmal AF patients (PAF) (101 patients undergone CA) and 60 healthy subjects. Serum levels of sema4D were measured and study participants were followed-up for 3 months and 1 year since CA in terms of recurrence respectively.Sema4D levels were significantly elevated in the recurrent group compared to the non-recurrent PAF patients (Sema4D is a novel biomarker that may help to identify individuals with recurrence after CA procedure in long term period in PAF.

A novel technology able to measure the local impedance (LI) during radiofrequency ablation has become available for clinical use. We investigated the change in the LI characteristics during superior vena cava isolations (SVCIs) using a novel catheter equipped with mini-electrodes. Twenty paroxysmal atrial fibrillation patients (68 ± 9 years; 14 males) underwent an SVCI by targeting breakthroughs. Subsequently, dormant conduction provoked by adenosine triphosphate (ATP) was evaluated. Electrical SVCIs were successfully achieved in all with 7.2 ± 3.0 radiofrequency applications (RFA) without any complications. The procedure and fluoroscopic times were 13.1 ± 8.1 and 2.8 ± 2.3 min. No ablation was required at the anteroseptal SVC in 19 (95.0%) patients. The baseline LI and generator impedance (GI) were 125 ± 23 and 105 ± 14Ω. LI drops during RFA were significantly greater than GI drops (17 ± 12 vs. 4 ± 4Ω, p < 0.001). The correlation between the LI drops and GI drops was relatively high (R = 0.69, p < 0.001). LI drops were highest at the septal SVC and lowest at the lateral followed by antero-lateral SVC. The baseline electrogram amplitude between the mini-electrodes and tip-ring electrodes was 1.2 ± 1.4 and 0.8 ± 0.6 mV. The mini-electrode amplitude is more sharply attenuated with a greater magnitude than the tip-ring amplitude (p < 0.001). ATP-provoked dormant conduction was exposed in 10/17 (58.8%) patients and antero-lateral SVC gap locations in 7. Antero-lateral SVC LI drops were similar between patients with and without dormancy. The LI drop magnitude during RFA significantly differed among the SVC segments. Antero-lateral SVC ATP-provoked dormant conduction was often exposed, and additional applications are recommended following the isolation for a robust SVCI.

Background The success rate after cryoballoon ablation (CB-A) performed for paroxysmal atrial fibrillation (PAF) might be overestimated by traditional noninvasive monitoring techniques. The purpose of this study was to evaluate the mid-term outcome of CB-A in patients with PAF implanted with an implantable loop recorder (ILR) after the procedure. Methods Between January 2017 and March 2019, all patients who underwent CB-A for PAF and who were subsequently implanted with an ILR were retrospectively included. All devices were equipped with remote monitoring. All ILR-documented atrial tachycardia (AT) or AF episodes ≥ 6 min were considered as recurrence; both true and false episodes were collected. A 3-month post-procedural blanking period (BP) was applied. Results A total of 102 patients (77 men, mean age 60.6 ± 9.6 years) who underwent pulmonary vein isolation (PVI) by CB-A were included; mean time from first diagnosis of AF to PVI was 51.5 ± 46.9 months. Mean follow-up was 29.3 ± 8.1 months; at 12-month follow-up, the success rate was 65.7%, while at 2-year follow-up, freedom from AT/AF recurrences was achieved in 59.3% of the patients. In the follow-up, a total of 4987 ECG strips were analyzed; true-positive episodes were confirmed in 2026 cases (40.6%), whereas 2961 episodes (59.4%) were considered false-positive. Conclusion In patients with PAF implanted with an ILR, CB-A results in freedom from any AT/AF recurrence in 65.7% of patients at 12-month follow-up and in 59.3% of patients when evaluated at 2-year. Careful adjudication of all ILR-documented AF episodes is required to avoid misdiagnosis.

Antiarrhythmic drug therapy (ADT) and catheter ablation (CA) are the main treatments for paroxysmal atrial fibrillation. However, the short- and long-term clinical efficacy of these treatments remains controversial. Our goal is to investigate efficacy and safety of the standardized treatment of elderly patients with paroxysmal atrial fibrillation (PAF). Eight randomized controlled trials on CA and ADT for treating PAF were included. Totally, 1336 patients were included. Studies on CA and ADT for treating PAF that were published between January 2005 and June 2020 in the Cochrane Library, PubMed and EMBASE were screened and identified. Atrial fibrillation-free rates and Short Form (SF-36) health score-related indexes were analyzed. Atrial fibrillation-free rates were similar in the CA and ADT groups [risk ratio (RR) 1.32; 95% confidence interval (CI) 0.96-1.82; P = 0.08] at 3 months. The CA group had a significantly higher atrial fibrillation-free rate at 6 months (RR 1.87; 95% CI 1.38-2.53; P < 0.001), 9 months (RR 2.38; 95% CI 1.43-3.96; P < 0.001), and 12 months (RR 2.21; 95% CI 1.28-3.84; P=0.005). However, there was no significant difference in terms of long-term efficacy at 24 months (RR 1.81; 95% CI 0.97-3.36; P = 0.06). The 12-month QOL physical and mental components (RR 2.41; 95% CI 0.89-3.93; P = 0.002) were significantly higher in CA group. The CA is more effective than ADT in the short-term prognosis. But the long-term prognosis of PAF needs to be verified via randomized controlled trials with longer follow-up durations.

DIAMOND-AF (DiamondTemp™ Ablation System for the Treatment of Paroxysmal Atrial Fibrillation) was a prospective, multicenter, noninferiority, randomized trial that compared the safety and effectiveness of the DTA system versus those of a force-sensing RF ablation system (control) for the treatment of patients with drug-refractory, recurrent, symptomatic paroxysmal atrial fibrillation (AF).Irrigated radiofrequency (RF) ablation catheters lose tissue temperature acuity, which is vital in assessing lesion formation. DiamondTemp Ablation (DTA) was designed to re-establish accurate tissue temperature measurements during ablation.A total of 482 patients with paroxysmal AF were randomized (239 DTA, 243 control) to undergo pulmonary vein isolation and were followed up at 23 sites. Patients were screened for disease progression, cardiac characteristics, and prior interventions. Primary endpoints were effectiveness (freedom from atrial arrhythmia recurrence) and safety (composite of procedure- and device-related serious adverse events).The primary safety event rate was 3.3% in the DTA group versus 6.6% in the control group (p 0.001 vs. 6.5% noninferiority margin). Primary effectiveness was met in 79.1% of DTA subjects and 75.7% of control subjects (p 0.001 vs. -12.5% noninferiority margin). Secondary endpoint analysis found that off-drug effectiveness favored DTA compared with the control (142 [59.4%] vs. 120 [49.4%], respectively; p = 0.03). Total RF time and individual RF ablation duration were significantly shorter with less saline infused through the DTA catheter (p 0.001). Both arms saw clinically meaningful improvements in quality of life at 12 months.Safety and efficacy of the DTA system proved noninferior to force-sensing RF ablation in a paroxysmal AF population. Efficiencies were observed using DTA with shorter total RF times, individual RF ablation durations, and less saline infusion. (DiamondTemp™ Ablation System for the Treatment of Paroxysmal Atrial Fibrillation; NCT03334630).

A case report of cryoballoon ablation for atrial fibrillation in a patient after atrial septal defect closure is presented.

We report a bilateral thoracoscopic technique in which robot-assisted mitral valve repair was achieved concomitantly with stapler division of the large left atrial appendage. The patient was a 65-year-old male with severe mitral regurgitation, paroxysmal atrial fibrillation and a large-sized atrial appendage. Closure of the appendage was completed off-pump using a left thoracoscopic stapler-division technique previous to right thoracoscopic robot-assisted mitral valve repair and cryoablation. Complete closure of the appendage was confirmed in thoracoscopic views. The bilateral thoracoscopic technique could be preferable for the minimally invasive treatment of mitral valvular disease and concomitant large-sized atrial appendage management., Robot-assisted totally endoscopic mitral valve repair has been developed as an option for mitral valve procedures [1].

Electrical isolation of pulmonary vein ostia is an established therapy for paroxysmal atrial fibrillation. The purpose of this study is to evaluate the long-term efficacy and safety of cryoballoon catheter ablation in paroxysmal atrial fibrillation with normal anatomy of the left atrium. Two hundred fifteen consecutive patients were included in the study (from November 2014 to November 2016). All the patients had symptoms of paroxysmal atrial fibrillation resistant to antiarrhythmic drugs and underwent pulmonary vein cryoisolation using second-generation cryoballoons. Standard “single-shot” cryoballoon exposures were used alternately for each of the four pulmonary veins. The endpoint of the ablation procedure was the electrical isolation of each pulmonary vein. Sixty-nine patients had stable atrial fibrillation recurrences and left atrial flutter with 30 of 69 patients having atrial fibrillation paroxysms during the first year after primary ablation. Repeated ablation was performed within 6–12 months after the first ablation. In 39 of 69 cases, arrhythmia recurrences were registered during the second and third year after the first ablation. These patients underwent repeated ablation within 12–36 months after the first ablation. In 98% of the patients, no disease progression with a transition to a persistent form of atrial fibrillation was observed. During the mean 5-year follow-up period, no disease progression with the transition to persistent forms of atrial fibrillation was observed. It was concluded that in patients with paroxysmal atrial fibrillation, with normal left atrium anatomy and no risk factors, it can be controlled with single pulmonary vein isolation without additional atrial substrate modification.

Background: Patent foramen ovale (PFO) is a common abnormality, occurring in about 25% of the population. Percutaneous PFO closure is recommended for selected patients in the prevention of recurrent thromboembolic events. Although transcatheter closure of PFO is recognized as a safe procedure, potential complications, such as atrial fibrillation, may occur. The purpose of this study was to assess the prevalence of arrhythmia in patients before and after PFO closure. Methods: We retrospectively reviewed the medical records of 45 patients (median age, 45 [IQR, 35–61] years; 80% female) who underwent percutaneous PFO closure. 24‑hour Holter electrocardiograms were done both before and 3 months after the procedure in 21 patients (median age, 49 [38–65] years; 81% female), however data of predominant underlying rhythm was available for all 45 patients. Results: There were no statistically significant differences in maximal and minimal heart rate, number of supraventricular and ventricular extrasystolic beats, pauses, episodes of supraventricular and ventricular tachycardia in patients before and after the PFO closure procedure. Median average heart rate was significantly higher before the procedure (70 [67–78] bpm vs 69 [62–77] bpm; p = 0,03). Among the 45 patients, one had a history of paroxysmal atrial fibrillation (AF) before the procedure. During the follow‑up, no AF was found. Conclusions: 1) Transcatheter closure of PFO did not affect arrhythmias observed in 24‑hour Holter ECG monitoring of our patients. 2) The procedure has a low risk of complications if performed in selected patients by an adequately trained operator in an experienced center.

To assess safety and efficacy of nonfluoroscopic cryoballoon ablation, 32 patients with symptomatic drug resistant paroxysmal atrial fibrillation were treated.

We present a case of transcatheter heart valve thrombosis in a 76-year-old man with paroxysmal atrial fibrillation on therapeutic anticoagulation with apixaban and polycythemia vera. The incidence of transcatheter heart valve thrombosis in patients with atrial fibrillation and on adequate anticoagulation is not well reported. (Level of Difficulty: Intermediate.), Graphical abstract

Background In patients with symptomatic paroxysmal atrial fibrillation that has not responded to medication, catheter ablation is more effective than antiarrhythmic drug therapy for mainta...

Funding Acknowledgements Type of funding sources: None. Introduction The risk of procedure-related complications and rhythm outcomes differ between men and women after atrial fibrillation catheter ablation (AFCA). We evaluated whether consistent sex differences existed in mapping and rhythm outcomes in repeat ablation procedures. Methods Among 3,282 patients in the registry, we analysed 443 consecutive patients (24.6% female, 58.5 ± 10.3 years old, 61.5% paroxysmal AF) who underwent a second AFCA. We compared the clinical factors, mapping, left atrial (LA) pressure, complications, and long-term clinical recurrences after propensity score matching. Results The LA volume index (43.1 ± 18.6 vs. 35.8 ± 11.6 ml/m2, p Conclusions During the repeat AFCA procedures, PV reconnections were lower in women than men, and the existence of extra-PV triggers and an LA pressure elevation was more significant, which resulted in poor rhythm outcomes.

Poyendarone, a deuterated analogue of dronedarone, is expected to reduce the onset of cardiovascular adverse events of dronedarone, including congestive heart failure and excessive QT-interval prolongation. Since information is still lacking on the anti-atrial fibrillatory property of poyendarone, we assessed it along with effects on the inter-atrial conduction time (IACT) and atrial effective refractory period (AERP) using the canine paroxysmal atrial fibrillation model. Poyendarone hydrochloride (n = 4) and dronedarone hydrochloride (n = 4) in intravenous doses of 0.3 and 3 mg/kg/30 s were cumulatively administered. Poyendarone hardly altered sinoatrial rate, but dronedarone decreased it in a dose-related manner, whereas both drugs slightly but significantly reduced idioventricular rate. Poyendarone shortened duration of burst pacing-induced atrial fibrillation, whereas such abbreviation was not observed by dronedarone. Poyendarone and dronedarone similarly prolonged IACT in a frequency-dependent manner, indicating that their INa inhibitory actions may be similar. The high dose of poyendarone prolonged AERP in a reverse frequency-dependent manner, extent of which at basic pacing cycle lengths of 300 and 400 ms was comparable to that of dronedarone. However, the extent at a basic pacing cycle length of 200 ms was tended to be greater in poyendarone than in dronedarone, suggesting greater IKs inhibitory action of poyendarone. The deuteration of dronedarone attenuated the inhibition of sinus automaticity and prolonged the AERP with keeping the blood pressure and ventricular rate stable. Thus, poyendarone may have both more potent anti-atrial fibrillatory action and wider cardiovascular safety margin than dronedarone.

Introduction Given that few studies investigated the efficacy of catheter ablation (CA) in patients with paroxysmal atrial fibrillation (AF) and atrial septal defect (ASD), this study evaluated its effectiveness in patients with paroxysmal AF and ASD. Methods and results Of the 216 patients who underwent ASD device closure at two hospitals, 36 patients had paroxysmal AF. After April 2012, CA for AF was performed before ASD device closure (ASD-CA group; n = 20). The ASD-CA group had a significantly higher AF-free survival rate after ASD device closure compared to patients without CA for AF before ASD device closure (ASD-non-CA group; n = 16) (ASD-CA group: 2 patients vs. ASD-non-CA group: 9 patients; follow-up period: 4.2 ± 2.5 years; log-rank p = 0.01). In addition, the AF-free survival rates were similar between the ASD-CA group and 80 paroxysmal AF patients who underwent CA without any detectable structural heart disease (non-SHD-CA group). The two groups were matched by propensity scores for age, sex, and left atrium dimension (ASD-CA group: 2 patients vs. non-SHD-CA group: 5 patients; follow-up period: 3.3 ± 1.8 years; log-rank p = 0.28). Conclusion CA for AF before ASD device closure might be an effective treatment option for patients with paroxysmal AF and ASD. This article is protected by copyright. All rights reserved.

Introduction A significant improvement in safety and efficacy of ablation for paroxysmal atrial fibrillation (PAF) has been reported by experienced centers over recent years; however, data from real-life surveys and smaller electrophysiology (EP) laboratories have been less optimistic. Aim To asses efficacy of ablation for PAF in a middle-volume EP center over last years. Methods Retrospective analysis of 1 year efficacy and safety of ablation for PAF in three cohorts of patients treated between 2011 and 2014 (period I), 2015–2017 (period II), and 2018–2019 (period III). Results Of 234 patients (mean age 57 ± 9 years, 165 males), 81 (35%) were treated in period I, 84 (36%) in period II, and 69 (29%) in period III. The overall efficacy of ablation during all analyzed periods was 67%. The overall efficacy of ablation increased over time—from 56% in period I to 68% in period II and 81% in period III. Significant improvement was achieved using radiofrequency ablation (RF) (53% in period I vs 82% in period III, and 55% in period II vs 82% in period III, p = 0.003 and 0.0012, respectively) whereas positive trend in the improvement of cryoballoon efficacy was NS. The rate of peri-procedural complications was 9% and it did not change significantly over time. Conclusions This real-life observational study from a medium volume EP center shows that progress in PAF ablation, especially RF, reported by highly-skilled centers, can be reproduced in real life by less experienced operators.

An 86-year-old man with paroxysmal atrial fibrillation on flecainide, a class IC antiarrhythmic, presented with cardiac arrest. The patient had extremely wide QRS complexes with inconsistent pacemaker capture on electrocardiography. Due to cardiac failure and renal failure, the patient developed progressive flecainide toxicity, which led to pacemaker failure, and ultimately, death. (Level of Difficulty: Beginner.), Central Illustration

For years, there has been an increase in cases of atrial fibrillation, reaching alarming levels. This is why intense work is done to find predictors of this arrhythmia. The electrocardiogram has shown to be useful for this purpose, and multiple indices derived from the P wave have been developed. Among the most notable is the P wave dispersion (PWD). It has been verified that PWD can predict the occurrence of paroxysmal atrial fibrillation in the absence of diseases as well as in the context of multiple cardiovascular pathologies or other systems. PWD is considered by most researchers to be the result of inhomogeneous conduction of the atrial electrical impulse, but a vector explanation may play a role in its genesis. The large body of evidence surrounding PWD supports its use in clinical practice.

Background Paroxysmal atrial fibrillation (PAF) can be triggered by non-pulmonary vein foci, like the superior vena cava (SVC). The latter is correlated with improved result in terms of freedom from atrial tachycardias (ATs), when electrical isolation of this vessel utilizing radiofrequency energy (RF) is achieved. Objectives Evaluate the clinical impact, in patients with PAF, of the SVC isolation (SVCi) in addition to ordinary pulmonary vein isolation (PVI) by means of the second-generation cryoballoon (CB) Methods A total of 100 consecutive patients that underwent CB ablation for PAF were retrospectively selected. Fifty consecutive patients received PVI followed by SVCi by CB application, and the following 50 consecutive patients received standard PVI. All patients were followed 12 months. Results The mean time to SVCi was 36.7 ± 29.0 s and temperature at SVC isolation was − 35 (− 18 to − 40) °C. Real-time recording (RTR) during SVCi was observed in 42 (84.0%) patients. At the end of 12 months of follow-up, freedom from ATs was achieved in 36 (72%) patients in the PVI only group and in 45 (90%) patients of the SVC and PV isolation group (Fisher’s exact test p = 0.039, binary logistic regression: p = 0.027, OR = 0.28, 95%CI = 0.09–0.86). In survival analysis, SVC and PV isolation group was also associated with improved freedom from ATs (log-rank test: p = 0.017, Cox regression: p = 0.026, HR = 0.31, 95%CI = 0.11–0.87). Conclusion Superior vena cava isolation with the CB in addition to PVI might improve freedom from ATs if compared to PVI alone at 1-year follow-up.

BackgroundIn this study considering the relationship between serum endocan and CHA2DS2-VASc score, we assumed that endocan level could be a new biomarker for stroke risk in patients with paroxysmal atrial fibrillation (PAF). It was examined that endocan could be an alternative to determine the risk of stroke and anticoagulation strategy in patients with PAF. The CHA2DS2-VASc scores were calculated for 192 patients with PAF, and their serum endocan levels were measured. The patients were divided into two groups as those with low to moderate (0-1) and those with high (≥ 2) CHA2DS2-VASc scores, and the endocan levels were compared between these two groups.ResultsThe serum endocan level was significantly higher in the high CHA2DS2-VASc score group (p< 0.001). In the multivariate logistic regression analysis, endocan, C-reactive protein, and low-density lipoprotein were found to be independent determinants of the CHA2DS2-VASc score. The predictive value of endocan was analyzed using the ROC curve analysis, which revealed that endocan predicted a high stroke risk (CHA2DS2-VASc ≥ 2) at 82.5% sensitivity and 71.2% specificity at the cutoff value of 1.342.ConclusionThis study indicates that endocan is significantly associated with CHA2DS2-VASc score. We demonstrated that endocan could be a new biomarker for the prediction of a high stroke risk among patients diagnosed with PAF.

Някои от факторите за рецидив на предсърдно мъждене (ПМ) след изолация на белодробните вени са наличието на левопредсърдна (ЛП) дилатация, както и наличието и обширността на зони с абнормен миокарден волтаж в ЛП. Целта ни беше да проучим честотата на рецидивите след първа аблация на ПМ при пациенти със и без ЛП дилатация или абнормен миокарден волтаж при проследяване. Материал и методи. Извършено е ретроспективно проучване на пациенти с пристъпно ПМ и първа изолация на белодробни вени, предхождана от високоплътностен волтажен мепинг в синусов ритъм. Проучени са клинични и процедурни характеристики, преживяемост без рецидив и предиктори за рецидив. Стойност на р < 0.05 е приета за сигнификантна. Резултати. Проучени са 63-ма пациенти (65% мъже). Средната продължителност на проследяване е 12 месеца след изтичане на тримесечния заслепен период. Преживяемостта без рецидив на 12-ия месец е 74.8%, но варира силно в зависимост от наличието на ЛП дилатация или на ранни рецидиви в заслепения период. При пациенти с недилатирано ЛП преживяемостта без аритмии е 82% срещу 66% при тези с ЛП дилатация, HR = 2.61, 95% CI 1.06-6.41, logrank p = 0.07. Пациентите без ранен рецидив имат 12-месечна преживяемост без последващ рецидив от 83.8% срещу 52% при тези с ранен рецидив, HR 4.17, 95% CI 1.48-11.76, logrank p = 0.001. Не се установиха разлики в наличието и площта на зони с абнормен волтаж при пациенти със и без рецидиви. Заключение. Рецидивите на ПМ след електрическа изолация на белодробните вени 15 месеца след процедурата са 25%, но честотата им зависи в голяма степен от възниква- нето на ранни рецидиви по време на заслепения период и от степента на ЛП дилатация. The presence of left atrial (LA) dilation, as well as the presence and extent of LA zones with abnormal myocardial voltage are among the factors for recurrence of atrial fibrillation (AF) after pulmonary vein isolation (PVI). Our aim was to study the rate of recurrences after first ablation for AF in patients with and without LA dilation or abnormal myocardial voltage at follow-up. Material and Methods. This is a retrospective study of patients with paroxysmal AF and first PVI preceded by high density voltage mapping in sinus rhythm. Clinical and procedural characteristics, recurrence-free survival and predictors for recurrence were studied. P value < 0.05 was considered significant. Results. Sixty-three patients (65% males) were studied. Mean follow- up duration was 12 months beyond the end of the 3-month blinding period. Recurrence-free survival at 12 months was 74.8% and varied widely with the presence of LA dilation or early recurrences within the blinding period. In patients with non-dilated LA arrhythmia-free survival was 82% vs. 66% in those with LA dilation, HR = 2.61, 95% CI 1.06-6.41, logrank p = 0.07. Patients without early recurrence had 12-month recurrence-free survival of 83.8% vs. 52% in those with early recurrence, HR 4.17, 95% CI 1.48-11.76, logrank p = 0.001. The presence and area of abnormal voltage zones were not different in patients with and without recurrence. Conclusion. The rate of AF recurrences after PVI at 15 months after the procedure was 25%, but it depended highly on the early recurrences during the blinding period and the degree of LA dilation.

Background The effect of type of atrial fibrillation (AF) on adverse outcomes in Chinese patients without oral anticoagulants (OAC) was controversial. Hypothesis The type of AF associated with adverse outcomes in Chinese patients without OAC. Methods A total of 1358 AF patients without OAC from a multicenter, prospective, observational study was included for analysis. Univariable and multivariable Cox regression models were utilized. Net reclassification improvement analysis was performed for the assessment of risk prediction models. Results There were 896(66%) patients enrolled with non‐paroxysmal AF (NPAF) and 462(34%) with paroxysmal AF (PAF). The median age was 70.9 ± 12.6 years, and 682 patients (50.2%) were female. During 1 year of follow‐up, 215(16.4%) patients died, and 107 (8.1%) patients experienced thromboembolic events. Compared with the PAF group, NPAF group had a notably higher incidence of all‐cause mortality (20.2% vs. 9.4%, p