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Objectives The aim of this study was to evaluate the efficacy of radiofrequency (RF) energy applications targeting the atrial side of a significant residual leak in patients with acute and chronic evidence of incomplete percutaneous left atrial appendage (LAA) occlusion. Background RF applications have been proved to prevent recanalization of intracranial aneurysms after coil embolization, thereby favoring complete sealing. From a mechanistic standpoint, in vitro and in vivo experiments have demonstrated that RF promotes collagen deposition and tissue retraction. Methods Forty-three patients (mean age 75 ± 7 years mean CHA2DS2-VASc score 4.6 ± 1.4, mean HAS-BLED score 4.0 ± 1.1) with residual leaks ≥4 mm after Watchman implantation were enrolled. Procedural success was defined as complete LAA occlusion or presence of a mild or minimal (1- to 2-mm) peridevice leak on follow-up transesophageal echocardiography (TEE), which was performed approximately 45 days after the procedure. Results RF-based leak closure was performed acutely after Watchman implantation in 19 patients (44.2%) or scheduled after evidence of significant leaks on follow-up TEE in 24 others (55.8%). The median leak size was 5 mm (range: 4-7 mm). On average, 18 ± 7 RF applications per patient (mean maximum contact force 16 ± 3 g, mean power 44 ± 2 W, mean RF time 5.1 ± 2.5 minutes) were performed targeting the atrial edge of the leak. Post-RF median leak size was 0 mm (range: 0-1 mm). A very low rate (2.3% [n = 1]) of major periprocedural complications was observed. Follow-up TEE revealed complete LAA sealing in 23 patients (53.5%) and negligible residual leaks in 15 (34.9%). Conclusions RF applications targeting the atrial edge of a significant peri-Watchman leak may promote LAA sealing via tissue remodeling, without increasing complications. (RF Applications for Residual LAA Leaks [REACT]; NCT04726943 )

Objectives This study evaluated the long-term efficacy of a standard antithrombotic strategy versus half-dose direct oral anticoagulation (DOAC) after Watchman implantation. Background No consensus currently exists on the selection of the most effective antithrombotic strategy to prevent device-related thrombosis (DRT) in patients undergoing endocardial left atrial appendage closure. Methods After successful left atrial appendage closure, consecutive patients were prescribed a standard antithrombotic strategy (SAT) or long-term half-dose DOAC (hdDOAC). The primary composite endpoint was DRT and thromboembolic (TE) and bleeding events. Results Overall, 555 patients (mean age 75 ± 8 years, 63% male; median CHA2DS2-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 4 [interquartile range (IQR): 3-6]; median HAS-BLED [hypertension, abnormal renal or liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol] score 3 [IQR: 2-4]) were included. Patients were categorized into 2 groups (SAT: n = 357 vs hdDOAC: n = 198). Baseline clinical characteristics were similar between groups. The median follow-up duration was 13 months (IQR: 12-15 months). DRT occurred in 12 (2.1%) patients, all in the SAT group (3.4% vs 0.0%; log-rank P = 0.009). The risk of nonprocedural major bleeding was significantly more favorable in the hdDOAC group (0.5% vs. 3.9%; log-rank P = 0.018). The rate of the primary composite endpoint of DRT and TE and major bleeding events was 9.5% in SAT patients and 1.0% in hdDOAC patients (HR: 9.8; 95% CI: 2.3-40.7; P = 0.002). Conclusions After successful Watchman implantation, long-term half-dose DOAC significantly reduced the risk of the composite endpoint of DRT and TE and major bleeding events compared with a standard, antiplatelet-based, antithrombotic therapy.

Atrial fibrillation (AF) is a complex and multi-factorial rhythm disorder. Catheter ablation is widely used for the management of AF. However, it is limited by relapse of the arrhythmia necessitating repeat procedures.This review aims to discuss the predictors of post-ablation recurrent AF including age, gender, genetic predisposition, AF type and duration, comorbidities, lifestyle factors, echocardiographic parameters of heart chambers, left atrial fibrosis and ablation strategies and targets. An extensive literature search was undertaken on PubMed and Google Scholar to obtain full texts of relevant AF-related articles.Maintenance of stable sinus rhythm is the main intended outcome of AF ablation. Therefore, it is very crucial to identify the risk factors that may influence the ablation success. Most of these predictors such as comorbidities, ablation strategy and targets and lifestyle factors are either reversible or modifiable. Thus, not only the awareness of these known risk factors by both patients and their physicians but also future research to identify the unknown predictors are critical to optimize care in this multi-faceted morbidity.

INTRODUCTION Primary objective was to evaluate baseline characteristics for catatonic patients treated with and without electroconvulsive therapy (ECT). We also studied the trends of ECT utilization in catatonia patients. METHODS The Nationwide Inpatient Sample data were used to compare patients and hospital-level characteristics between catatonic patients treated with and without ECT in the United States. Multivariate and trend analysis were performed. RESULTS Electroconvulsive therapy was performed in 8.3% in patients with the diagnosis of catatonia (n = 24,311; mean age, 43.1; 38% White; 52.1% male). Racially, more patients in the ECT group were White (47% vs 38%) and had a comorbid diagnosis of major depressive disorder. In the multivariate analysis, the odds of receiving ECT was more with increase in age (P = 0.007). Urban area hospitals had 3 times higher odds of receiving ECT (P = 0.001) compared with rural hospitals. The odds of receiving ECT for catatonia were the highest for large bed hospitals compared with small/medium size (P < 0.001). In the trend analysis, catatonia patients undergoing ECT decreased initially from 7.0% in 2002 to 2005 to 5.2% in 2006 to 2009. After that, there was an upward trend with 10.6% patients undergoing ECT in the quarter 2014 to 2017. There was an upward trend in ECT utilization for catatonic patients with comorbid bipolar disorders and psychotic disorders. CONCLUSIONS Electroconvulsive therapy is underutilized for catatonia treatment in the United States. White catatonic patients are most likely to get ECT at an urban large bed hospital. In recent years, there is an upward trend in the use of ECT. Additional controlled clinical trials are warranted.

Objectives This study evaluated the association of the post-ablation scar with stroke risk in patients undergoing atrial fibrillation (AF) ablation. Background Late gadolinium enhancement–...

Background The creation of effective and permanent lesions is a crucial factor in determining the success rate of atrial fibrillation (AF) ablation. By increasing the efficacy of radiofrequency (RF) energy-mediated lesion formation, half-normal saline (HNS) as an irrigant for open-irrigated ablation catheters has the potential to reduce procedural times and improve acute and long-term outcomes. Methods This is a double-blind randomized clinical trial of 99 patients undergoing first-time RF catheter ablation for AF. Patients enrolled were randomly assigned in a 1:1 fashion to perform ablation using HNS or normal saline (NS) as an irrigant for the ablation catheter. Results The use of HNS is associated with shorter RF times (26 vs. 33 min; p = .02) with comparable procedure times (104 vs. 104 min). The rate of acute pulmonary vein reconnections (16% vs. 18%) was comparable, with a median of 1 vein reconnection in the HNS arm versus 2 in the NS arm. There was no difference in procedure-related complications, including the incidence of postprocedural hyponatremia when using HNS. Over the 1-year follow-up, there is no significant difference between the HNS and NS with respect to the recurrence of any atrial arrhythmia (off antiarrhythmic drugs [AAD]: 47% vs. 52%; hazard ratio [HR]: 1.17, 95% confidence interval [CI]: 0.66-2.06; off/on AAD: 66% vs. 66%, HR: 1.06, 95% CI: 0.53-2.12), with a potential benefit of using HNS when considering the paroxysmal AF cohort (on/off AAD 73% vs. 62%, HR: 0.72, 95% CI: 0.19-2.70). Conclusions In a mixed cohort of patients undergoing first-time AF ablation, irrigation of open-irrigated RF ablation catheters with HNS is associated with shorter RF times, with a comparably low rate of procedure-related complications. In the long term, there is no significant difference with respect to the recurrence of any atrial arrhythmia. Larger studies with a more homogeneous population are necessary to determine whether HNS improves clinical outcomes.

OBJECTIVES Electroconvulsive therapy (ECT) is controversial in children and adolescents (C/A). The primary objective of this study was to evaluate baseline characteristics of C/A in the utilization of ECT compared with the non-ECT group with the same primary indication. The secondary objective was to assess the trends in ECT utilization over 16 years and explore the predictors of length of stay. METHODS Using the Nationwide Inpatient Sample database from the years 2002 to 2017, we identified patients (age ≤18 years) undergoing ECT in the United States using International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification/Procedure Coding System codes and compared with non-ECT C/A patients with the same primary diagnosis. Baseline clinical characteristics were assessed using descriptive analysis methods. Multilevel regression analysis and trend analysis were performed. RESULTS Children and adolescent patients (n = 159,158) receiving (ECT: n = 1870) were more likely to be men (43.3% vs 36.7%) and of White race (58% vs 49%) (P < 0.001). The hospital stay was longer (19 days vs 6 days, P < 0.001) for the ECT group than controls. ECT receiving C/A patients were more likely to have private insurance (72% vs 42%, P < 0.001). African American patients undergoing ECT treatment increased in number over the course of years (2002 to 2017), whereas the privately insured C/A patients receiving ECT decreased over the same period (P < 0.001). There was an upward trend in ECT utilization for small bed size hospitals (P < 0.001). Length of stay for C/A receiving ECT was longer for males (P < 0.001) and patients with nonprivate insurance (p: 0.003). CONCLUSIONS Electroconvulsive therapy is not optimally used in C/A; therefore, formulated treatment guidelines are required.

AimsLeft atrial appendage electrical isolation (LAAEI) has been shown to improve freedom from all-atrial arrhythmia recurrence in patients with non-paroxysmal atrial fibrillation (AF). The aim of this study is to investigate the long-term efficacy and safety outcomes of LAAEI in patients with non-paroxysmal AF undergoing catheter ablation.Methods and resultsA systematic review of Medline, Cochrane, and Embase was performed for clinical studies evaluating the benefit of LAAEI in non-paroxysmal AF. Nine studies with a total of 2336 patients were included (mean age: 65 ± 9 years, 63% male). All studies included patients with persistent AF, long-standing persistent AF, or both. At a mean follow-up of 40.5 months, patients who underwent LAAEI had significantly higher freedom from all-atrial arrhythmia recurrence than patients who underwent standard ablation alone [69.3% vs. 46.4%; risk ratio (RR) 0.54; 95% confidence interval (CI) 0.42–0.69; P ConclusionAt long-term follow-up, LAAEI led to a significantly higher improvement in freedom from all-atrial arrhythmia recurrence in patients with non-paroxysmal AF, when compared to standard ablation alone. Importantly, this benefit was achieved without an increased risk of acute procedural complications or cerebral thromboembolic events.

Background Thromboembolic stroke is a rare but devastating consequence of atrial fibrillation (AF) ablation. Transesopheageal echocardiography (TEE) is recommended to rule out left atrial appendage thrombus (LAA); however, its utilization is variable. Objective To assess whether TEE is mandatory in patients undergoing AF ablation on uninterrupted DOACs. Methods Data from our prospective, multicenter registry of AF patients undergoing radiofrequency catheter ablation on uninterrupted DOACs was analyzed. All included patients were on anticoagulation for at least four-weeks before ablation. All AF ablation procedures were performed under ICE guidance. Prior to transseptal puncture, heparin bolus was administered, followed by continuous infusion, with target activated clotting time over 300 seconds. Results A total of 6186 patients [3180 (51.4%): apixaban, 2528 (40.9%): rivaroxaban, 404 (6.5%): dabigatran, and 74 (1.2%): edoxaban] were analyzed. The mean age of the study population was 69.4 ± 10.3 years, of which 4194 (67.8%) patients were male and 5120 (82.8%) patients had persistent and long-standing persistent AF. The mean CHA2DS2-VASc score was 2.86 ± 1.58; the mean CHADS2 score was 1.65 ± 1.14. ICE ruled out LAA and LA thrombus in all patients and revealed ‘smoke’ in 1672 (27.03%) patients. Transient ischemic attack was noted in one patient with long-standing persistent AF, in the setting of a missed dose of rivaroxaban prior to ablation. Conclusion Our study showed that performance of AF ablation in patients on uninterrupted DOACs without TEE is safe and feasible in high stroke-risk patients. Elimination of routine pre-ablation TEE would have significant economic and clinical implications.

The percutaneous epicardial approach has become an adjunctive tool for electrophysiologists to treat disparate cardiac arrhythmias, including accessory pathways, atrial tachycardia, and particularly ventricular tachycardia. This novel technique prompted a strong impulse to perform epicardial access as an alternative strategy for pacing and defibrillation, left atrial appendage exclusion, heart failure with preserved ejection fraction, and genetically engineered tissue delivery. However, because of the incremental risk of major complications compared with stand-alone endocardial ablation, it is still practiced in a limited number of highly experienced centers across the world.

BACKGROUND We evaluated the efficacy of a new method in identifying peri-device leak (PDL) using morphology of the thrombus formed inside the left atrial appendage (LAA) as seen on follow-up transesophageal echo (TEE). METHOD A total of 291 consecutive patients undergoing Watchman procedure were included in this analysis. TEE was performed at 45 days postprocedure. Based on the presence of the thrombus inside the LAA behind the device, patients were grouped as (1) white (W) group: LAA completely filled with thrombus (n = 101), 2) nonwhite (NW) group: LAA completely black or mixed (part black and part white; n = 190). Follow-up TEE was repeated at 6 and 12 months. RESULTS Baseline characteristics were comparable between groups except the device size, number of patients with chicken-wing morphology, and prevalence of left atrial "smoke" that were significantly higher in the NW group. Detection of black appearance was comparable between the pre-coil closure image and the NW population (26/36 [72.2%] vs 99/154 [64.3%], p = .37). After adjusting for clinically relevant covariates, NW appearance of the LAA was associated with the presence of significant leak (odds ratio: 47.96, 95% confidence interval: 2.91-790.2, p

Rhythm control of persistent atrial fibrillation (AF) patients represents a challenge for the modern interventional cardiac electrophysiologist; as a matter of fact, there is still divergence regarding the best ablative approach to adopt in this population. Different investigational endpoints, variability of techniques and tools, significant technological evolution, and the lack of universally accepted pathophysiological models engendered a considerable heterogeneity in terms of techniques and outcomes, so much that the treatment of persistent subtypes of AF commonly still relies mainly on pulmonary vein (PV) isolation. The purpose of the present review is to report the current experimental and clinical evidence supporting the importance of mapping and ablating non-PV triggers and describe our institutional approach for the ablation of nonparoxysmal AF.

BACKGROUND The pathologic process of ARVC (arrhythmogenic right ventricular cardiomyopathy) typically originates in the epicardium or subepicardial layers with progression toward endocardium. However, in the most recent ARVC international task force consensus statement, epicardial ventricular tachycardia (VT) ablation is recommended as a Class I indication only in patients with at least one failed endocardial VT ablation attempt. OBJECTIVE The aim of this meta-analysis is to assess the outcomes of ARVC patients undergoing combined endo-epicardial VT ablation, as compared to endocardial ablation alone. METHODS A systematic review of PubMed, Embase, and Cochrane was performed for studies reporting clinical outcomes of endo-epicardial VT ablation vs endocardial-only VT ablation in patients with ARVC. Fixed-Effect model was used if I2 < 25 and the Random-Effects Model was used if I2 ≥ 25%. RESULTS Nine studies consisting of 452 patients were included (mean age 42.3 ± 5.7 years; 70% male). After a mean follow-up of 48.1 ± 21.5 months, endo-epicardial ablation was associated with 42% relative risk reduction in VA recurrence as opposed to endocardial ablation alone (risk ratio [RR], 0.58; 95% confidence interval [CI], 0.45-0.75; P

When patients have symptomatic recurrent atrial tachyarrhythmias after 2 months following pulmonary vein antral isolation, a repeat ablation should be considered. Patients might present with isolated pulmonary veins posterior wall. In these patients, posterior wall isolation is extended, and non-pulmonary vein triggers are actively sought and ablated. Moreover, in those with non-paroxysmal atrial fibrillation or a known higher prevalence of non-pulmonary vein triggers, empirical isolation of the superior vena cava, coronary sinus, and/or left atrial appendage might be performed. In this review, we will focus on ablation of non-pulmonary vein triggers, summarizing our current approach for their mapping and ablation.

Atrioesophageal fistula (AEF) is a rare but deadly complication of radiofrequency ablation for atrial fibrillation. Given its rarity, the diagnosis of AEF is usually delayed with a wide variation in management strategies, which contribute to the high mortality associated with AEF. As such, the most important step of AEF management is prevention, whereas early diagnosis and treatment are crucial to reduce its associated high mortality.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the authors. The authors inadvertently specified some ablation settings in the methods section that should not have been reported because they can be potentially linked to a specific pulsed field ablation technology that is currently under investigation for FDA approval. The Authors apologize for the inconvenience caused by this oversightinsert 'Reason' text (to be provided by the Editor-in-Chief or written by the Publisher and approved by the Editor-in-Chief and then approved by the RR panel). In case of (suspected) plagiarism, it is mandatory to refer to the plagiarized work here byAbbreviated Journal Title, volume (year) first page - last page, http://dx.doi.org/DOI of plagiarized work (in URL format) coded as inter-ref if possible.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the authors. The authors inadvertently specified some ablation settings in the methods section that should not have been reported because they can be potentially linked to a specific pulsed field ablation technology that is currently under investigation for FDA approval. The Authors apologize for the inconvenience caused by this oversightinsert 'Reason' text (to be provided by the Editor-in-Chief or written by the Publisher and approved by the Editor-in-Chief and then approved by the RR panel). In case of (suspected) plagiarism, it is mandatory to refer to the plagiarized work here byAbbreviated Journal Title, volume (year) first page - last page, http://dx.doi.org/DOI of plagiarized work (in URL format) coded as inter-ref if possible.

In the past decade, the use of interventional electrophysiological (EP) procedures for the diagnosis and treatment of cardiac arrhythmias has exponentially increased. These procedures usually require fluoroscopy to guide the advancement and frequent repositioning of intracardiac catheters, resulting in both the patient and the operator being subjected to a considerable degree of radiation exposure. Although shielding options such as lead gowns, glasses, and pull-down shields are useful for protecting the operator, they do not lessen the patient’s level of exposure. Furthermore, the prolonged use of lead gowns can exponentiate the onset of orthopedic problems among operators. Recent advancements in three-dimensional cardiac mapping systems and the use of radiation-free imaging technologies such as magnetic resonance imaging and intracardiac ultrasound allow operators to perform EP procedures with minimal or even no fluoroscopy. In this review, we sought to describe the state of fluoroless procedures in EP practice.

Left atrial appendage (LAA) is the dominant source of systemic thromboembolic (TE) events in patients with nonvalvular atrial fibrillation (AF). In patients with significant bleeding risk, various LAA exclusion strategies have been developed as an alternative to pharmacologic TE prophylaxis. Nevertheless, in a relatively small percentage of patients, incomplete LAA closure can be documented, either at the time of procedure or during follow-up. This persistent patency can potentially jeopardize an effective stroke prophylaxis. Hereby, we report an update on the current clinical implications of LAA leaks and how to manage them.

Background Fragmented QRS (fQRS) on 12-lead electrocardiography is a noninvasive marker of intramyocardial conduction delay due to ventricular scarring that has not previously been studied in atrial fibrillation. Objective The purpose of this study was to assess the association of fQRS with left atrial (LA) scarring in patients with persistent atrial fibrillation (PsAF) undergoing first catheter ablation. Methods A total of 376 patients with PsAF were enrolled. Severity of LA scarring was assessed using electroanatomic mapping. Narrow fQRS was defined by the presence of an additional R wave (R′) or notching in the nadir of the S wave, or the presence of >1 R′ in 2 contiguous leads corresponding to inferior, lateral, or anterior myocardial regions. Results Both any degree (97.3% vs 63.3%) and severe (42.2% vs 6.3%) LA scarring were higher in patients with fQRS. Age and fQRS were found to be independent predictors of severe LA scarring. At multiple ventricular regions, fQRS had diagnostic accuracy of 79.8% for prediction of severe LA scarring. Nonpulmonary vein triggers were more often detected and ablated in patients with fQRS and severe LA scarring (84.4% vs 70%; P = .001). Atrial tachyarrhythmia recurrence was observed in 131 patients (34.8%) during 18.9 ± 7.7 months of follow-up, which was significantly higher in patients with fQRS (53.2% vs 16.8%). In multivariate analysis, fQRS was found to be a significant predictor of recurrence (hazard ratio 4.65; 95% interval confidence 2.91–7.42; P Conclusion The study results showed that fQRS is a simple, available, and noninvasive marker, and that fQRS at multiple ventricular regions is significantly associated with the severity of LA scarring in PsAF patients.

Loss of contractility leading to stasis of blood flow following left atrial appendage electrical isolation (LAAEI) could lead to thrombus formation.This study evaluated the incidence of thromboembolic events (TE) in post-LAAEI cases "on" and "off" oral anticoagulation (OAC).A total of 1,854 consecutive post-LAAEI patients with follow-up transesophageal echocardiography (TEE) performed in sinus rhythm at 6 months to assess left atrial appendage (LAA) function were included in this analysis.The TEE at 6 months revealed preserved LAA velocity, contractility, and consistent A waves in 336 (18%) and abnormal parameters in the remaining 1,518 patients. In the post-ablation period, all 336 patients with preserved LAA function were off OAC. At long-term follow-up, patients with normal LAA function did not experience any stroke events. Of the 1,518 patients with abnormal LAA contractility, 1,086 remained on OAC, and the incidence of stroke/transient ischemic attack (TIA) in this population was 18 of 1,086 (1.7%), whereas the number of TE events in the off-OAC patients (n = 432) was 72 (16.7%); p 0.001. Of the 90 patients with stroke, 84 received left atrial appendage occlusion (LAAO) devices. At median 12.4 months (interquartile range: 9.8 to 15.3 months) of device implantation, 2 (2.4%) patients were on OAC because of high stroke risk or personal preference, whereas 81 patients discontinued OAC after LAAO device implantation without any TE events.LAAEI is associated with a significant risk of stroke that can be effectively reduced by optimal uninterrupted OAC or LAAO devices.

Background Atrial fibrillation (AF) triggers within the coronary sinus (CS)/great cardiac vein (GCV) and the left atrial appendage (LAA) have been recognized as nonpulmonary vein triggers of AF. Objective The aim of this study was to describe an electrical connection between the LAA and CS/GCV and its importance in achieving LAA electrical isolation (LAAEI). Methods A total of 488 consecutive patients undergoing catheter ablation for persistent or long-standing persistent AF who showed firing from the LAA and/or from the CS/GCV were enrolled in this multicenter prospective study. In all patients, potential defragmentation of the CS/GCV to achieve isolation and LAAEI was attempted with both endocardial and epicardial ablation. Results In 7% (n = 34) of these patients, after attempting endocardial LAAEI, the LAA was isolated during epicardial ablation in the GCV. In 8% (n = 39) of patients after attempting endocardial LAA isolation, the LAA was isolated during ablation along the endocardial aspect of the GCV. The presence of a venous branch connecting the GCV with the LAA was found in all these patients. In 23% (n = 112) of patients, the isolation of the LAA also isolated the GCV. In all these patients, LAA dissociated firing was present together with the CS/GCV recordings. Conclusion These findings suggest the presence of a distinct electrical connection between the GCV and the LAA. The clinical relevance of our results requires further investigation. Ablation in the CS/GCV can result in inadvertent isolation of the LAA. Ablation of the GCV is relevant to achieve LAAEI. Considering the potential long-term implications, ablation in the distal CS/GCV should prompt assessment of LAA conduction.

The optimal site of ablation of idiopathic left ventricular outflow tract (LVOT) ventricular arrhythmias (VAs) is challenging as activation mapping can reveal similar activation times in different anatomical sites, suggesting an intramural origin.We sought to assess whether in patients with intramural VAs and with multiple early activation sites (EASs), sequential ablation of all the early EASs could improve acute and long-term clinical outcomes.A total of 116 patients undergoing catheter ablation for symptomatic LVOT VAs were enrolled in this study. Thirty-nine patients (34%) were referred for a redo procedure, whereas the remaining presented for a first procedure. Mapping was performed manually in 86 cases (74%) and with a magnetic robotic system (Niobe, Stereotaxis, St. Louis, MO) in the remainder of the cases.Of the 116 patients, 15 (13%) were found to have multiple sites of equally early activation. In patients with multiple EASs, the mean pre-QRS activation time was significantly less than in patients with a single EASs (-26 ± 3 ms vs -38 ± 6 ms; P .005). Sequential ablation of all the EASs was possible in 14 patients (93%), resulting in complete arrhythmia suppression. After a mean follow-up of 21 ± 5 months, all patients with successful ablation of all multiple early EASs remained free from clinical VAs.Intramural LVOT VAs manifesting with multiple EASs require ablation at all sites to achieve acute and long-term success, particularly if none of the EASs is-30ms pre-QRS activation time.

Background: Optimal duration of energy delivery in high-power short-duration (HPSD) ablation to create a durable lesion in atrial fibrillation (AF) is not clear yet. We evaluated the association of electrical reconnection with lesion duration in HPSD-ablation. Methods: HPSD ablation was defined as maximum temperature at 42 °C and power delivery at 45 W for 10 to 15 seconds (5 seconds in coronary sinus [CS] and left atrial posterior wall [LAPW] near the esophagus). In some patients, a mechanical tool was used to deflect the esophagus away from the ablation site. Results: Consecutive 1749 patients with AF (left atrial appendage and CS isolation: 1451) receiving redo ablation after a prior HPSD procedure were included. At the HPSD ablation, mean duration of lesion was significantly shorter in the LAPW facing esophagus compared with elsewhere (5.2±1.5 versus 12.5±1.7 seconds, P Conclusions: HPSD ablation with lesion duration of

Taranjeet Jolly,1 Zeeshan Mansuri,2 Chintan Trivedi,3 Mahwish Adnan,4 Steven P Cohen,5 To-Nhu Vu6 1Department of Psychiatry & Behavioral Health, Penn State University College of Medicine, Inpatient Child and Adolescent Psychiatry, Pennsylvania Psychiatric Institute, Harrisburg, PA, USA; 2Department of Psychiatry, Boston Children’s Hospital/Harvard Medical School, Boston, MA, USA; 3Psychiatry Department, St. David’s Medical Center, Austin, TX, USA; 4Department of Psychiatry, Mercy Hospital and Medical Center, Lincolnwood, IL, USA; 5Department of Anesthesiology & Critical Care medicine, Neurology and Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD, USA; 6Department of Anesthesia & Pain Medicine, Penn State University College of Medicine, Hershey, PA, USACorrespondence: Taranjeet JollyDepartment of Psychiatry & Behavioral Health, Penn State College of Medicine, Inpatient Child and Adolescent Psychiatry, Pennsylvania Psychiatric Institute, 2501 N 3rd Street, Harrisburg, PA, USATel +1 734-837-6549Email tjolly@pennstatehealth.psu.eduObjective: Data defining and subsequently guiding the use of psychotropic medications in children and adolescents is sparse. We conducted a meta-analysis of randomized control trials to examine the effectiveness of psychotropic medications in children and adolescents with chronic pain.Methods: We conducted a comprehensive literature search from published studies, and annual scientific sessions of psychiatry conferences. We identified double-blind, randomized control trials (RCTs) in which psychotropic medications were compared to placebo. Data was collected for the total number of patients, baseline characteristics, and changes in pain score. Meta-analysis was performed using a random effect model evaluating average change in pain score and the number of patients with a reduction in pain score for both groups. Pooled data are expressed as standardized mean differences (SMD) and odds ratios (OR) with 95% confidence intervals (CI).Results: We found 5 studies that included amitriptyline (n=2), citalopram (n=1), buspirone (n=1) and duloxetine (n=1). In the pooled analysis for the difference in the average change in pain score, 4 RCTs with 395 patients were included. After 12– 13 weeks of therapy, reductions in pain score were significantly greater in the psychotropic drug group as compared to placebo (SMD: − 0.77, 95% CI − 1.54, 0.0001, p= 0.05). For the analysis on the number of patients with a reduction in pain, data were available for 445 patients (224-medication group, 221-placebo group). More patients in the psychotropic drug group experienced a meaningful reduction in pain score at 12– 13 weeks of therapy compared to placebo (OR 1.66, 95% CI 1.08– 2.54, p= 0.02).Conclusion: The results of this meta-analysis demonstrate significant analgesic efficacy of psychotropic medications in the management of children with chronic pain. This review is limited by the small number of studies included for analysis. There is a pressing need for more robust clinical trials to further investigate these promising findings.Keywords: chronic pediatric pain, psychotropic, anti-depressants, anti-anxiety medications, meta-analysis

BACKGROUND Atrioesophageal fistula (AEF) is a worrisome complication of atrial fibrillation (AF) ablation. Its clinical manifestations and time course are unpredictable and may contribute to diagnostic and treatment delays. We conducted a systematic review of all available cases of AEF, aiming at characterizing clinical presentation, time course, diagnostic pitfalls, and outcomes. METHODS The digital search retrieved 150 studies containing 257 cases, 238 (92.6%) of which with a confirmed diagnosis of AEF and 19 (7.4%) of pericardioesophageal fistula. RESULTS The median time from ablation to symptom onset was 21 days (interquartile range [IQR]: 11-28). Neurological abnormalities were documented in 75% of patients. Compared to patients seen by a specialist, those evaluated at a walk-in clinic or community hospital had a significantly greater delay between symptom onset and hospital admission (median: 2.5 day [IQR: 1-8] vs. 1 day [IQR: 1-5); p = .03). Overall, 198 patients underwent a chest scan (computed tomography [CT]: 192 patients and magnetic resonance imaging [MRI]: 6 patients), 48 (24.2%; 46 CT and 2 MRI) of whom had normal/unremarkable findings. Time from hospital admission to diagnostic confirmation was significantly longer in patients with a first normal/unremarkable chest scan (p

Introduction Empirical pulmonary vein isolation (PVI) remains the cornerstone for catheter ablation of atrial fibrillation (AF). Various ablation strategies and modalities are continually tested with the aim of improving ablation outcomes. Although focal impulse and rotor modulation (FIRM)-guided ablation is currently used as an adjunct to pulmonary vein isolation (PVI), evidence supporting this strategy is conflicting. We sought to examine whether the utilization of FIRM-guided ablation with or without PVI is associated with a decrease in all-atrial arrhythmia recurrence as compared to PVI alone. Methods A systematic review of PubMed, Cochrane, and Embase was performed for head-to-head study designs comparing outcomes of patients who underwent FIRM-guided ablation with or without PVI to those who underwent PVI. The primary efficacy endpoint was all-atrial arrhythmia recurrence. The secondary endpoint was complication rates. Results Overall, six studies comprising 716 patients undergoing either FIRM-guided ablation +/- PVI vs PVI were included (mean age 63.4 ± 9.2, male 74%, 11.5% paroxysmal AF, 88.5% non-paroxysmal AF). After a mean follow-up of 18.8 months, FIRM-guided ablation with or without PVI was not associated with improvement in all-atrial arrhythmia recurrence rate compared to PVI alone (43.4% vs 45.9%, Risk Ratio [RR] 1.06, 95% Confidence Interval [CI] 0.77-1.47, P=0.70). No statistically significant difference was noted in complication rates between the two groups (RR 1.66, 95% CI 0.08-34.54, P=0.74). Conclusion In this meta-analysis of head-to-head comparisons, FIRM-guided ablation with or without PVI did not provide any benefit in improving all-atrial arrhythmia recurrence at follow-up when compared to PVI alone. This article is protected by copyright. All rights reserved.

Central pontine myelinolysis (CPM) is demyelinating condition of pons caused by osmotic stress due to rapid correction of hyponatremia. We present a case where CPM was an incidental finding on FDG PET/CT scan. To the best of our knowledge, only 3 case reports have been published till date describing CPM on 18F-FDG PET/CT scans.

Background We evaluated long‐term outcome of isolation of pulmonary veins, left atrial posterior wall, and superior vena cava, including time to recurrence and prevalent triggering foci at repeat ablation in patients with paroxysmal atrial fibrillation with or without cardiovascular comorbidities. Methods and Results A total of 1633 consecutive patients with paroxysmal atrial fibrillation that were arrhythmia‐free for 2 years following the index ablation were classified into: group 1 (without comorbidities); n=692 and group 2 (with comorbidities); n=941. We excluded patients with documented ablation of areas other than pulmonary veins, the left atrial posterior wall, and the superior vena cava at the index procedure. At 10 years after an average of 1.2 procedures, 215 (31%) and 480 (51%) patients had recurrence with median time to recurrence being 7.4 (interquartile interval [IQI] 4.3–8.5) and 5.6 (IQI 3.8–8.3) years in group 1 and 2, respectively. A total of 201 (93.5%) and 456 (95%) patients from group 1 and 2 underwent redo ablation; 147/201 and 414/456 received left atrial appendage and coronary sinus isolation and 54/201 and 42/456 had left atrial lines and flutter ablation. At 2 years after the redo, 134 (91.1%) and 391 (94.4%) patients from group 1 and 2 receiving left atrial appendage/coronary sinus isolation remained arrhythmia‐free whereas sinus rhythm was maintained in 4 (7.4%) and 3 (7.1%) patients in respective groups undergoing empirical lines and flutter ablation ( P Conclusions Very late recurrence of atrial fibrillation after successful isolation of pulmonary veins, regardless of the comorbidity profile, was majorly driven by non‐pulmonary vein triggers and ablation of these foci resulted in high success rate. However, presence of comorbidities was associated with significantly earlier recurrence.

Background We compared the cognitive status and quality of life in patients with atrial fibrillation undergoing left atrial appendage occlusion (LAAO) or remaining on oral anticoagulation (OAC) after atrial fibrillation ablation. Methods and Results Cognition was assessed by the Montreal Cognitive Assessment (MoCA) survey at baseline and follow‐up. Consecutive patients receiving LAAO or OAC after atrial fibrillation ablation were screened, and patients with a score of ≤17 were excluded from the study. Quality of life was measured at baseline and 1 year using the Atrial Fibrillation Effect on Quality of Life survey. A total of 50 patients (CHA 2 DS 2 ‐VASc [congestive heart failure, hypertension, age≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65–74 years, sex category] score: 3.30±1.43) in the LAAO group and 48 (CHA 2 DS 2 ‐VASc score 2.73±1.25) in the OAC group were included in this prospective study. Mean baseline MoCA score was 26.18 and 26.08 in the LAAO and OAC groups, respectively ( P =0.846). At 1 year, scores were 26.94 and 23.38 in the respective groups. MoCA score decreased by an estimated −2.74 (95% CI, −3.61 to −1.87; P P =0.07). After adjusting for baseline clinical characteristics, remaining on OAC was an independent predictor of MoCA change at 1 year (regression coefficient, −3.38; 95% CI, −4.75 to −2.02; P Conclusions In this series, a significant difference in the postprocedure MoCA score was observed in postablation patients with atrial fibrillation receiving LAAO versus remaining on OAC with a substantial decline in the score in the OAC group. However, quality of life improved similarly across groups. Registration https://www.ClinicalTrials.gov . Unique identifier: NCT01816308

BACKGROUND This study evaluated the arrhythmia profile and ablation outcome in women with atrial fibrillation (AF) aged ≥75 years. METHODS A total of 573 consecutive female patients undergoing first AF ablation were classified into group 1: ≥75 years (n = 221) and group 2

We read with great interest the article Sucksdorff et al. "Maternal Vitamin D Levels and the Risk of Offspring Attention-Deficit/Hyperactivity Disorder."1 We commend the authors for this extraordinary work. Several studies have explored this association lately as well.2 It is logistically challenging to conduct this type of study, as it requires long-term follow-up and patient compliance in a vulnerable population. In this letter, we aim to provide a few suggestions for the statistical methodological aspect, which can better guide the clinician in predicting ADHD among offspring.

BACKGROUND Major depressive disorder (MDD) is the most common psychiatric disorder characterized by changes in mood, cognition, and physical symptoms. MDD has an approximate 18% prevalence of comorbid OSA. Several studies have looked into plausible mechanisms that have shown a strong relationship between OSA and MDD. OBJECTIVES The primary objective of this study was to compare suicidal ideation/attempt among MDD patients with and without a comorbid diagnosis of OSA. The secondary objective was to compare the length of stay, total hospital charge, recurrent or severity of depression, and clinical comorbidities. METHODS Data were obtained from the National (Nationwide) Inpatient Sample dataset from 2006 to 2017. For data collection, we queried for all adult patients (age ≥ 18 y), with MDD as a primary indication of admission. Further, we categorized MDD patients with and without a secondary diagnosis of OSA. To reduce the imbalance in baseline characteristics between the groups, we performed one to one age-gender matching between MDD patients with and without OSA. RESULTS In the matched cohort, 79,308 patients were included in MDD with OSA and 78,792 patients in the MDD without OSA group. MDD patients with OSA were more likely to be racially white (80% vs 75%, P < 0.001), and to have more clinical comorbidities (hypertension, heart failure, obesity, and chronic lung disease). Prevalence of recurrent type of depression (77% vs 69%, P < 0.001) and moderate to severe depression (72% vs 68%, P

Objectives This study sought to report the incidence of device-related thrombosis (DRT) and thromboembolic (TE) events when an alternative to clopidogrel is prescribed in loss-of-function (LOF) allele carriers of the cytochrome P450 2C19 (CYP2C19) gene. Background LOF polymorphisms of the CYP2C19 gene are associated with reduced hepatic bioactivation of clopidogrel. Methods One thousand two Watchman patients were included. Six hundred forty-five patients underwent CYP2C19 genetic testing; among patients with clopidogrel resistance, clopidogrel was replaced by either prasugrel (pilot cohort) or half dose direct oral anticoagulant ((DOAC)/Group 1), both in combination with aspirin. We compared the incidence of DRT/TE events among genotyped patients and a control group which received standard dual antiplatelet therapy (DAPT) (Group 2; n = 357). All reported events occurred during a timeframe between 45- and 180-day follow-up transesophageal echocardiograms, when the 2 different antithrombotic strategies (genotype-guided vs standard DAPT) were adopted. Results In the pilot cohort (n = 244), bleeding events occurred in 10.2% of patients who received aspirin plus prasugrel, leading to early discontinuation of the prasugrel-based protocol. DOAC Group 1 patients (n = 401), 25.7% were reduced metabolizers, and clopidogrel was replaced by half dose direct oral anticoagulant. DRT was documented in 1 (0.2%) patient of Group 1 and 7 (1.96%) patients of Group 2 (log-rank P value = 0.021). The composite endpoint of DRT/TE events was significantly lower among patients receiving a genotype-guided antithrombotic strategy (0.75% vs 3.1%; log-rank P value = 0.017). Conclusions In Watchman patients, a genotype-based antithrombotic strategy with aspirin plus half dose DOAC in reduced clopidogrel metabolizers was superior to standard DAPT with respect to DRT/TE events.

Aims We evaluated the efficacy of an ablation strategy empirically targeting pulmonary veins (PVs) and posterior wall (PW) and the prevalence and clinical impact of extrapulmonary trigger inducibility and ablation in a large cohort of patients with persistent atrial fibrillation (PerAF). Methods and Results A total of 1803 PerAF patients were prospectively enrolled. All patients underwent pulmonary vein antrum isolation (PVAI) extended to the entire PW. A standardized protocol was performed to confirm persistent PVAI and elicit any triggers originating from non-PV sites. All non-PV triggers initiating sustained atrial tachyarrhythmias were ablated. Ablation of non-PV sites triggering non-sustained runs ( Conclusion Pulmonary vein antrum isolation extended to the entire PW might provide acceptable long-term arrhythmia-free survival in PerAF patients without inducible non-PV triggers. In our population of PerAF patients, non-PV triggers could be elicited in ∼70% of PerAF patients and their elimination significantly improved outcomes.

Introduction: Loss-of-function (LOF) polymorphisms of the cytochrome P450 2C19 (CYP2C19) gene are associated with reduced hepatic bioactivation of clopidogrel. Hypothesis: To evaluate the prevalence of LOF polymorphisms of CYP2C19 and the incidence of device-related thrombosis (DRT) when clopidogrel is replaced with half dose novel oral anticoagulant (NOAC) in patients with reduced clopidogrel metabolism. Methods: Consecutive Watchman patients were genotyped for CYP2C19 polymorphisms. Patients with reduced clopidogrel metabolism received half dose NOAC plus aspirin during the “dual antiplatelet therapy (DAPT) phase” post-Watchman implantation (between 45 days and 6 months). The incidence of DRT among genotyped patients (Group I, n=401) and a control group without genotypization (Group II, n=357) which received standard DAPT is reported. Results: Overall, 758 Watchman patients were included (mean age: 75±8 yrs, 63% males, CHA 2 DS 2 -VASc: 4.6±1.5; HAS-BLED: 3.2±1.1). Of the 401 Group 1 patients, 25.69% (n=103) were reduced clopidogrel metabolizers. In 87.4% of them, clopidogrel was replaced with half-dose NOAC during the “DAPT phase” post-Watchman implantation whereas 12.6% received ASA plus full-dose NOAC due to the presence of a significant peri-device leak. During the “DAPT phase”, DRT was documented in 1 (0.2%) patient of Group I and 7 (1.96%) patients of Group II (p=0.029). On multivariate analysis, a genotype-tailored antithrombotic strategy was associated with a significant reduction in DRT (odds ratio: 0.11; 95% confidence interval: 0.01 - 0.98; p-value: 0.048). Conclusions: Approximately 25% of our Watchman patients had clopidogrel resistance. Substitution of clopidogrel with half dose NOAC in reduced clopidogrel metabolizers significantly reduced the incidence of DRT.

Background: A considerable proportion of elderly patients are known to have coexistent atrial fibrillation (AF) and amyloidosis. Both conditions increase stroke risk. Objective: We evaluated the best anticoagulation strategy in a series of AF patients with amyloidosis. Methods: Consecutive AF patients with coexistent amyloidosis undergoing catheter ablation at our center were included in the analysis. Based on the stroke-prophylaxis approach they were divided into 2 groups; group 1: left atrial appendage occlusion (LAAO) with Watchman and group 2: oral anticoagulation. Following LAAO, all patients remained on full dose non-vitamin K oral anticoagulants (NOAC) for 45 days. Transesophageal echocardiogram (TEE) was performed at 45 days to assess completeness of closure. If the occlusion was complete, patients were kept on aspirin, 81 mg/day for long-term. In case of leak or dense ‘smoke’ in the left atrium (LA) or enlarged LA, they were prescribed half-dose NOAC. NOACs included dabigatran, apixaban, endoxaban and rivaroxaban. Group 2 patients remained on full-dose NOAC during the whole study period (1 year). All patients were prospectively followed up for 1 year. Results: A total of 87 patients were included in the analysis; group 1: 56 and group 2: 31 . CHA 2 DS 2 -VASc score was comparable between the groups (gr. 1: 3.7±1.6 and gr. 2: 3.2±1.7, p=0.18). The most commonly used NOACs were apixaban (45, 51.7%) and rivaroxaban (34, 39%). After the 45-day TEE, 34 patients from group 1 remained on baby-aspirin and 22 on half-dose NOAC. Of the 22, 12 patients had leaks Conclusion: In our series of patients with coexistent AF and amyloidosis, half-dose NOAC following LAA occlusion procedure was observed to be the safest stroke-prophylaxis strategy.

Introduction: General anesthesia is routinely used during the implantation of S-ICD which dramatically prolongs total procedure time, patient recovery time and adds unnecessary potential complications. The tumescent local anesthesia (TLA) technique provides anesthesia of large areas of skin and subcutaneous tissue by means of the direct infiltration of large volumes of a dilute local anesthetic solution into subcutaneous fat. Hypothesis: TLA during S-ICD implantation is feasible and associated with a reduction in total procedure time. Methods: A retrospective analysis was conducted in two medical centers during 2019. Five patients underwent S-ICD with TLA due to baseline conditions that represented relative contraindications to general anesthesia (e.g, muscular dystrophy). A large volume of a local anesthesia solution (i.e., 1 liter of normal saline, 30 cc of 1% lidocaine, 30 cc of bupivacaine, 1 mg of epinephrine, 12.5 mEq of sodium bicarbonate) was used in each patient and injected 10 minutes prior to incisions. Five other patients who underwent S-ICD under general anesthesia served as controls. The skin-to-skin time, total length of procedure and post-procedural pain levels were compared between groups. Results: A total of 10 patients were included (male: 60%; mean age: 62 ± 16). All devices were implanted for primary prevention of sudden cardiac death. TLA was considered the best anesthetic approach in five patients who had medical conditions that represented a high risk of complications if general anesthesia was employed. In the group of TLA, an average of 260 ± 45 cc was administered. The skin-to-skin times were 44.8 ± 13.9 minutes in patients who underwent general anesthesia vs. 46.2 ± 14.3 minutes in TLA (p = 0.3). The total procedural time was 148 ± 28 min vs 64.2 ± 13.4 min (p Conclusions: S-ICD implantation using TLA appears to be a feasible and safe option in patients with contraindications to general anesthesia. This technique significantly decreases total procedure time with better post-procedural pain control.

Background: Takotsubo syndrome (TTS) has been reported in up to 10% of women with a clinical presentation suggestive of acute coronary syndrome (ACS), making the differential diagnosis challenging. Chromogranin-A (CgA) is a pro-hormone co-released with catecholamines. Elevated levels of CgA are found in ACS and in exacerbations of congestive heart failure (CHF), indicating an imbalance of the neuroendocrine system. Hypothesis: CgA levels in women with TTS might differ from levels in other conditions featuring acute heart failure. Methods: We systematically screened CgA levels in 54 consecutive women admitted with TTS (n=29) or either CHF exacerbation or ACS (n=25) between November 2016 and September 2019. Clinical parameters including left ventricle ejection fraction, in-hospital events, troponin I (TnI), creatinine, and natriuretic peptide type B (NT-pro-BNP) values were recorded. Only samples obtained within 24 hours from symptom onset were analyzed. We excluded 18 subjects with TTS and 6 with ACS/CHF because of a history of cancer, chronic kidney disease >III stage, liver cirrhosis, or autoimmune disease. Results: Patients with TTS (Group 1, n=11) were compared with patients with ACS/CHF (Group 2, n=19). Subjects in Group 1 were significantly younger (mean age 67 vs 80, p Conclusion: In our population, systemic CgA levels collected within 24 hours from symptom onset were significantly lower in women with TTS compared to ACS/CHF, possibly indicating a different acute neuroendocrine pattern.

Introduction: The Transcatheter Leak Closure With Detachable Coils Following Incomplete Left Atrial Appendage Closure Procedures (TREASURE) is a prospective, nonrandomized, single-center study. This study was undertaken to investigate the efficacy of transcatheter leak closure with endovascular coils in patient with incomplete percutaneous/epicardial left atrial appendage (LAA) closure procedures and high thromboembolic (TE)- and bleeding-risk. Hypothesis: We report the efficacy of transcatheter leak closure with endovascular coils in patients with incomplete LAA closure. Methods: Sixty-five consecutive patients with a clinically relevant residual leak (mean age: 72±8 years; 73.8% males; CHA 2 DS 2 -VASc: 4.7±1.1; HAS-BLED: 3.7±0.7) underwent percutaneous closure of the LAA patency via embolization coils. Trans-esophageal echocardiography (TEE) was performed at 60±15 days post-procedure. Results: LAA closure had been previously attempted with a Watchman device in 62 patients, and a LARIAT in 3. Baseline TEE documented a moderate or severe leak in 14 (21.5%) and 51 (78.5%) patients, respectively. Procedure and fluoroscopy times were 69±37min and 22±15min, respectively; the mean volume of iodinated contrast medium used was 82±43mL. Coil deployment was successful in all cases [median n. of coils attempted: 3 (IQR:2-5); median n. of coils deployed: 3 (IQR: 2-4)]. The overall complication rate was 3.1% (1 pericardial tamponade, 1 pericardial effusion). Peri-procedural angiographic and TEE outcomes demonstrated complete obliteration or a negligible residual opacification with a trivial residual jet in 62 cases (95.4%), and a partial occlusion with moderate residual jet in 3 (6.4%). Follow-up TEE after 67±12 days revealed complete LAA sealing or a negligible residual leak in 63 cases (96.9%). Coil deployment led to an average reduction of 90.1% in leak size (p Conclusions: Transcatheter LAA leak occlusion via endovascular coils appears to be a safe, effective, and promising approach in high TE-risk patients with incomplete LAA closure.

Introduction: Radiofrequency catheter ablation (CA) is the preferred treatment for premature ventricular contractions (PVCs). Ionizing radiation has major side effects for both patients and personnel in the electrophysiology laboratory. Fluoroless procedures are routinely performed for atrial fibrillation and simple PVC cases. Nonetheless, left ventricular (LV) summit/intramural PVCs cases are more challenging and clinical outcomes and complications have been poorly studied in this category with the use of fluoroless ablation. Hypothesis: We aimed to compare acute, long-term success rate and complications between fluoroless procedures versus standard approach for left ventricular (LV) summit/intramural PVCs. Methods: We conducted a retrospective analysis of patients who underwent PVC ablation under fluoroscopy and non-fluoroscopy at two institutions. Results: A total of 41 cases were enrolled (male: 61%; mean age: 55 ). Twenty-five cases underwent ablation under fluoroscopy whereas 16 underwent non-fluoroscopy ablation. Acute success was seen in 88% of non-fluoroscopy cases compared to 87.5% in the fluoroscopy group ( p = 0.9). The PVC recurrence at 12 months was similar between both groups (non-fluoroscopy: 15% vs Fluoroscopy: 18%) ( p = 0.9). No complications occurred in any group. Conclusions: Fluoroless CA is an emerging technique in the treatment of LV summit/intramural PVCs that appears to have similar clinical outcomes and complications compared to conventional fluoroscopic procedures.

Introduction: Interventional therapies aiming at excluding the left atrial appendage (LAA) from systemic circulation have been established as a valid alternative to oral anticoagulation (OAC) in patients at high thromboembolic (TE) risk. However, their efficacy on stroke prophylaxis may be compromised owing to incomplete LAA closure. Additionally, the need for an alternative TE prevention may remain unmet in patients with contraindications to OAC whose appendage anatomy is unsuitable for some conventional devices commercially available. Hypothesis: We aimed at evaluating the feasibility of LAA closure with the novel Gore® Cardioform Septal Occluder (CSO) in patients with incomplete appendage ligation or anatomical features which do not meet the manufacturer’s requirements for Watchman deployment. Methods: Twenty-one consecutive patients (mean age: 72±6 years; 85.7% males; CHA 2 DS 2 -VASc: 4.5±1.4; HAS-BLED: 3.6±1.0) were included. Trans-esophageal echocardiography (TEE) was performed within 2 months to assess for residual LAA patency. Results: Fourteen patients had incomplete LAA closure following surgical (n=6) or Lariat ligation (n=8). In 7 patients with an appendage anatomy unsuitable for Watchman deployment, the mean maximal landing zone size and LAA depth were 14.4±1.3mm and 18.6±2.8mm. Successful CSO deployment was achieved in all patients. No peri-procedural complications were documented.Procedure and fluoroscopy times were 46±13min and 14±5min. Follow-up TEE after 58±9 days revealed complete LAA closure in all patients. Conclusions: Transcatheter LAA closure via a CSO device might be a valid alternative in patients with residual leaks following failed appendage ligation or whose LAA anatomy does not meet the minimal anatomical criteria to accommodate a Watchman device.

Introduction: Macro-reentrant arrhythmias involving the cavo-tricuspid isthmus (CTI) are common in patients with atrial fibrillation (AF). Bidirectional CTI block is the ablation strategy of choice, but it can be surprisingly difficult to obtain at times. Objective: Aim of this study was to systematically assess the characteristics of the CTI to determine its most common anatomical variants to be anticipated for ablation. Methods: This is a prospective observational study in which intracardiac echocardiography (ICE) was used to visualize the CTI of patients undergoing AF ablation. The presence of anatomical variants was recorded, and length was measured along the central CTI in atrial systole. CTI systolic shortening measured in sinus rhythm and defined as: [(diastolic length - systolic length)/(diastolic length)]x100. Results: 180 patients (65±9 years old, 31% female, 37% paroxysmal AF) are included in the study. Mean CTI length was 31±9 mm, with a systolic shortening of 25±13%. A prominent Eustachian ridge was present in 32%, a Chiari network in 11%, and at least one pouch-like recess in 35%, with a mean depth of 5.3±2.5 mm (Figure). A longer CTI was observed in patients with non-PAF compared with patients with PAF (33 vs. 27 mm, P Conclusion: Anatomical variants of the CTI are common and should be anticipated in case of a challenging CTI ablation. A long CTI is associated with OSA and might warrant further clinical screening to identify this common AF comorbidity. CTI systolic shortening correlates with the type of AF and could represent a measure of right atrial contractility.

Background: Transthyretin (TTR), a transport protein produced by liver, is closely associated with amyloidosis. Tetramers of TTR circulating in blood can dissociate to monomers that misassemble into amyloid fibrils. Although amyloidosis is a frequent finding in aged atrial fibrillation (AF) patients, the relevance of serum-TTR in AF is unknown. Objective: We evaluated if post-ablation change in serum-TTR level has any prognostic association with long-term ablation outcome in AF patients. Methods: One-hundred-forty-five patients (age: 62.8 ± 6.2years, male 69%, non-paroxysmal AF 41%, BMI : 30.8 ± 6.3) were included in this prospective study. Patients with chronic inflammatory conditions or taking anti-inflammatory drugs were excluded. All patients received pulmonary vein isolation plus isolation of left atrial posterior wall and superior vena cava. In non-paroxysmal AF, non-PV triggers identified by isoproterenol challenge were ablated. Fasting blood samples were collected at baseline and 24-hours post-ablation. Samples were tested for TTR using an automated quantitative test. Results: Mean TTR concentration was 27.94±6.5 mg/dL at baseline and 26.33±9.2 mg/dL at 24-hour post ablation (p Conclusion: Our findings demonstrated significant association of higher recurrence rate with decreased serum-TTR tetramer level at 24-hour post-ablation.

Background: Electrical isolation of the left atrial appendage (LAAEI) is considered in patients presenting with recurrence following effective PV isolation. Objective: We evaluated the prevalence of LAA reconnection following LAAEI in patients undergoing repeat procedure for AF recurrence. Methods: Consecutive AF patients undergoing repeat ablation for arrhythmia recurrence following LAAEI were included in this analysis. Transesophageal echocardiogram (TEE) was performed in all at baseline to evaluate LAA function. Isoproterenol infusion up to 30 μg/min for 10 to 15 min was administered to detect LAA triggers. Re-isolation of the LAA was performed if triggers were detected. Off-drug success rate was assessed in all. Results: A total of 594 post-LAAEI patients with recurrent AF were included in the analysis. At the redo, PVs were found to be electrically silent in all. LAA reconnection was detected in 214 (36%) patients. Baseline TEE revealed normal LAA contractility and flow-velocity in all. Re-isolation of the LAA was performed in these 214 patients. In patients with no LAA reconnection (n=380), non-PV triggers from other sites were targeted for ablation. There was no difference in the clinical characteristics of patients with vs. without LAA reconnection (Table). At 2 years after the repeat procedure, 201 (94%) patients with and 351 (92.3%) without LAA reconnection were arrhythmia-free off-drugs (p=0.47). Conclusion: In this series, LAA reconnection rate was 36% after single LAAEI procedure and re-isolation of the appendage led to high success rate. Additionally, normal LAA functions detected by TEE correctly predicted recovery of conduction in the LAA.

Background: Ablation strategy for long-standing persistent atrial fibrillation (LSPAF) is highly variable with diverse outcomes. Objective: We evaluated the change in left ventricular ejection fraction (LVEF) with different ablation approaches in LSPAF patients with heart failure (HF). Methods: Consecutive LSPAF patients with HF (LVEF group 1: received standard ablation (PV isolation+ isolation of left atrial posterior wall and superior vena cava) and group 2: standard ablation plus isolation of coronary sinus (CS) and left atrial appendage (LAA). High-dose isoproterenol challenge (20-30 μg for 10-15 min) was utilized to reveal LAA and CS triggers; electrical isolation was the procedural endpoint for LAA and CS ablation. If PVs were electrically silent due to presence of severe scar, LAA and CS were empirically isolated even in the absence of detectable triggers. LVEF was measured by transesophageal echocardiogram (TEE) performed at baseline and 6 months post-ablation. Patients were monitored for arrhythmia-recurrence off-antiarrhythmic drugs (AAD) as per our standard protocol. Results: Group 1 included 52 patients and group 2 had 106. Baseline characteristics were comparable across groups (age: 66.2 ± 7.3 and 64.4 ± 9.4; male: 41 (78.8%) and 87 (82.1%); BMI: 32.3 ± 6.8 and 30.4 ± 6.4 in group 1 and 2). Mean baseline LVEF (%) was 36.2±5.5 and 35.1±8.3 in group 1 and 2 respectively (p=NS). At the 6-month TEE, mean LVEF was significantly higher than the baseline value in group 2 (47.7±11 vs 35.1±8.3, p Conclusion: In our study population, ablation strategy including LAA and CS isolation along with the standard ablation resulted in significant improvement in the LVEF as well as higher rate of arrhythmia-free survival.