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Introduction There are several prognostic scores for the assessment of risk of atrial fibrillation (AF) recurrence post ablation procedure. However, the use of these complex scores is difficult and the validation on different populations brought divergent results. Our goal was to compare the performance of these risk scores as the basis for the development of a new, simplified score based only on few universally predictive variables. Methods All cryoballoon‐based AF ablations performed in a single‐center over a 10‐year period were prospectively analyzed with regard to AF recurrence. This served to analyze the performance of APPLE, CAAP‐AF, SCALE‐CryoAF, MB‐LATER, CHADS2, and CHA2DS2‐VASc risk scores. Results A total of 597 patients, mostly (78.1%) with paroxysmal AF were studied. Analyzed risk scores performed poorer than in the original publications because some risk factors were not predictive of AF recurrence. A simplified score named 0‐1‐2 PL, composed of just two universally predictive variables, AF type (1 point for P ersistent AF) and LA dimension (1 point for L A size >45 mm) was developed. The 0‐1‐2 PL score stratified patients into low risk (0 points), intermediate risk (1 point), and high risk categories (2 points) which were related to a 2‐year risk of AF recurrence of 21%, 37%, and 55%, respectively. This score had C‐statistics (0.620) higher/comparable to other investigated much more complex scores. Conclusion The assessment of risk of AF recurrence at the pre‐ablation stage can be simplified without compromising accuracy. This could help to popularize risk assessment and standardization of AF management., This study suggests that despite the significant differences between risk scores in terms of the choice of risk factors and the relative weights assigned to them, their performance for pre‐ablation risk assessment is quite similar, and weaker than originally reported. It seems that the assessment of the risk of AF recurrence at the pre‐ablation stage can be simplified by using the novel 0‐1‐2 PL score instead of more complex scores.

IntroductionOne of the challenges of left bundle branch (LBB) pacing is to place the pacing lead deep enough in the septum to obtain capture of the LBB, yet not too deep to avoid perforation. We hypothesized that the occurrence of the ectopic beats of qR/rsR’ morphology in V1 lead (fixation beats) during the lead fixation would predict that the final desired intraseptal lead depth was just reached, while the lack of fixation beats would indicate too shallow position, and need for more lead rotations.MethodsConsecutive patients during LBB pacing device implantation were analyzed retrospectively and then prospectively with respect to the occurrence of the fixation beats during each episode of lead rotation. We compared the presence of fixation beats during the lead rotation event directly before the LBB capture area depth was reached versus during the events before intermediate/unsuccessful positions.ResultsA total of 339 patients and 1278 lead rotation events were analyzed. In the retrospective phase, the fixation beats were observed in 327/339 of final lead positions and in 9/939 of intermediate lead positions (pConclusionsMonitoring fixation beats during deep septal lead deployment can facilitate the procedure and possibly increase the safety of lead implantation.

Background: Transesophageal echocardiography (TEE) allows detailed characterization of atrial fibrillation (AF) substrate and could be valuable for predicting pulmonary vein isolation (PVI) procedure outcomes. Aims: We aimed at assessing the value of TEE-derived left atrial (LA) and LA appendage (LAA) features as prognostic markers for AF recurrence after cryoballoon-based ablation. Methods: Patients were enrolled using a prospective database of consecutive PVI procedures performed over a 7-year period. The following TEE-derived parameters were investigated: LAA emptying flow velocity (LAA-FV), the presence of patent foramen ovale (PFO), LA spontaneous echo contrast, and mitral regurgitation. Diagnosis of AF recurrence was based on scheduled and symptoms triggered ECG monitoring. The Cox’s regression model and Kaplan-Meier survival curves were applied for statistical analysis. Results: A total of 417 consecutive patients who underwent their first PVI using cryoballoon were analyzed (mean age: 59 years). AF recurrence was noted in 25.7% of patients (median follow-up of 24 months). Four TEE-derived variables had predictive values for AF recurrence: LAA-FV

Introduction Permanent deep septal stimulation with capture of the left bundle branch (LBB) enables maintenance/restoration of the physiological activation of the left ventricle. However, it is almost always accompanied by the simultaneous engagement of the local septal myocardium, resulting in a fused (nonselective) QRS complex, therefore, confirmation of LBB capture remains difficult. Methods We hypothesized that programmed extrastimulus technique can differentiate nonselective LBB capture from myocardial-only capture as the effective refractory period (ERP) of the myocardium is different from the ERP of the LBB. Consecutive patients undergoing pacemaker implantation underwent programmed stimulation delivered from the lead implanted in a deep septal position. Responses to programmed stimulation were categorized on the basis of sudden change in the QRS morphology of the extrastimuli, observed when ERP of LBB or myocardium was encroached upon, as: "myocardial," "selective LBB," or nondiagnostic (unequivocal change of QRS morphology). Results Programmed deep septal stimulation was performed 269 times in 143 patients; in every patient with the use of a basic drive train of 600 milliseconds and in 126 patients also during intrinsic rhythm. The average septal-myocardial refractory period was shorter than the LBB refractory period: 263.0 ± 34.4 vs 318.0 ± 37.4 milliseconds. Responses diagnostic for LBB capture ("myocardial" or "selective LBB") were observed in 114 (79.7%) of patients. Conclusions A novel maneuver for the confirmation of LBB capture during deep septal stimulation was developed and found to enable definitive diagnosis by visualization of both components of the paced QRS complex: selective paced LBB QRS and myocardial-only paced QRS.

BackgroundDuring permanent deep septal pacing, it is important to confirm left bundle branch (LBB) capture.ObjectiveThe effective refractory period (ERP) of the working myocardium is different than the ERP of the LBB; we hypothesized that it should be possible to differentiate LBB capture from septal myocardial capture using programmed extra-stimulus technique.MethodsIn consecutive patients undergoing pacemaker implantation who received pacing lead in a deep septal position programmed pacing was delivered from this lead. Responses to programmed pacing were categorized on the basis of QRS morphology of the extrastimuli as: myocardial (broader QRS, often slurred), selective (narrower QRS, preceded by an isoelectric interval) or non-diagnostic (unequivocal change).ResultsProgrammed deep septal pacing was performed 269 times in 143 patients; in every patient with the use of an 8-beat basic drive train of 600 ms and when possible also during supraventricular rhythm. Responses diagnostic for LBB capture were observed in 114 (79.7%) of patients. Selective LBB paced QRS was more often seen when premature beats were introduced during the intrinsic rhythm rather than after the basic drive train. The average septal-myocardial refractory period was significantly shorter than the LBB refractory period: 263.0±34.4 ms vs. 318.0±37.4 ms.ConclusionsA novel maneuver for the diagnosis of LBB capture during deep septal pacing, was formulated, assessed and found as diagnostically valuable. This method, based on the differences in refractoriness between LBB and the septal myocardium is unique in enabling the visualization of components of the usually fused, non-selective LBB paced QRS complex.Graphical abstract

Background Due to limited data, implantable loop recorders (ILR) are not currently recommended by the guidelines to routinely monitor patients after atrial fibrillation (AF) ablation. Aims To validate the diagnostic value of ILR after AF ablation, modern generation ILRs (LINQ) were implanted in patients scheduled for cryoballoon ablation of AF (CBA). Methods We included 29 patients with frequent and symptomatic episodes of paroxysmal AF. ILR was implanted 3 months prior to CBA, and data were collected before and for 6 months after the procedure. The device was programmed to maximize sensitivity of AF/ atrial tachycardia (AT) detection. All EGM recordings were "manually" assessed and annotated as true AF, pseudo AF, unrecognized AF, and episodes with no EGM available. Duration and episode-based standard performance metrics were evaluated. Results A total number of 5,842 episodes were recorded. A total of 4,403 episodes were true AF, 453 episodes were pseudo AF, and 986 episodes had no EGM available. The device did not recognize 144 episodes of AF. Duration-based sensitivity was 95.2%, duration-based specificity 99.9%, duration-based PPV 99.2%, duration-based NPV 99.9%, episode-based sensitivity 98.0%, and episode-based PPV 91.0%. Misdiagnosis happened in 1 in 10 episodes. Total data review time was 166 hr. Conclusions Implantable loop recorders is a valuable tool in evaluation of AF episodes in patients undergoing CBA. However, for high precision all recorded episodes need to be evaluated "manually." The memory storage space is too low for frequent AF episodes, resulting in overwriting of stored EGMs and data loss.

Introduction The aim of this study was to determine whether baseline right ventricular (RV) function assessed by standard echocardiography may indicate patients who will respond to cardiac resynchronization therapy (CRT).

This editorial refers to ‘Transvenous phrenic nerve stimulation for the treatment of central sleep apnoea in heart failure’, by P. Ponikowski et al. , doi:10.1093/eurheartj/ehr298 The prevalence of central sleep apnoea (CSA) is 100-fold greater in chronic heart failure (HF) due to impaired systolic function than in the general population.1 It afflicts principally elderly male patients who have atrial fibrillation, implanted pacemakers, low arterial PCO2 when awake, or high diuretic requirements.1 Its presence identifies HF patients with higher night- and day-time sympathetic nervous system activity,2 at increased of risk of malignant ventricular arrhythmias,3 whose survival is foreshortened.4 The primary abnormality in CSA is neither the upper airway collapse of obstructive sleep apnoea (OSA), which can be treated quite effectively with continuous positive airway pressure (CPAP), nor a paucity of ventilation, but rather the compromise of mechanisms that normally stabilize breathing due to the confluence of pulmonary congestion, circulatory delay, altered cerebrovascular blood flow, and enhanced central sensitivity to CO2, all predisposing to hyperventilation.4 Although the reality is more complex, to simplify, in HF the cyclical oscillations between hyperpnoea and apnoea, known commonly as Cheyne–Stokes respiration, are initiated by the hyperpnoea, which can be stimulated by spontaneous arousal from sleep, or by pulmonary congestion. During sleep, the latter is exacerbated both by fluid shifts from the periphery to the cardiopulmonary reservoir,5 and by pre-existing pulmonary–cardiac–chemoreceptor circulatory delay. Thus, when increases in pulmonary capillary and venous pressures stimulate pulmonary irritant receptors, triggering a bout of hyperpnoea, the already low PaCO2 is driven below the patient's apnoeic threshold. Central drive to the muscles of breathing pauses until the rising PaCO2 and falling PaO2 are sensed, eventually, by chemoreceptors, which then initiate a new cycle of hyperpnoea, hypocapnia, and apnoea. CSA is …

Introduction: The aim of the study was to assess the relation of baseline mechanical dyssynchrony with the left ventricular end-systolic volume (LVESV) decrease following cardiac resynchronization (CRT) therapy introduction. Material and methods: Sixty consecutive patients (aged 66.3 ±8.7 years; 57 men) with chronic heart failure (71.7% of ischaemic and 28.3% of non-ischaemic origin) and current indications for CRT were assessed before and 3 months after biventricular heart stimulator implantation. Longitudinal movements of twelve segments of the left ventricle (LV) (6 basal and 6 midlevel) and two segments of the right ventricle (RV) were analysed using tissue Doppler imaging (TDI) techniques with time from onset of Q wave in ECG to peak systolic velocity in colour-coded TDI (TTDI ), time to peak strain (Tstrain) and time to peak strain rate (Tstrain rate). Minimal and maximal time differences within LV and between LV and RV walls were calculated. Results: In the study group LVEF and 6-min walk test distance increased, while NYHA class, NT-proBNP level, left ventricular end-diastolic volume and LVESV decreased. Significant correlations between the magnitude of LVESV reduction with maximal time differences between Tstrain of 12 LV segments (r = 0.34, p = 0.017) and time differences between TTDI basal LV-RV segments (r = –0.29, p = 0.041) were found. Conclusions: Only a few TDI-derived parameters such as maximal time differences between Tstrain of 12 LV segments and TTDI difference of LV-RV basal segments can be useful to predict the magnitude of left ventricle reverse remodelling after CRT introduction.