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ObjectivePulmonary vein isolation (PVI) guided by a standardised CLOSE (contiguous optimised lesions) protocol has been shown to increase clinical success after catheter ablation for paroxysmal atrial fibrillation (PAF). This study analysed healthcare utilisation and quality of life (QOL) outcomes from a large multicentre prospective study, measured association between QOL and atrial fibrillation (AF) burden and identified factors associated with lack of QOL improvement.MethodsCLOSE-guided ablation was performed in 329 consecutive patients (age 61.4 years, 60.8% male) with drug-refractory PAF in 17 European centres. QOL was measured at baseline and 12 months post-ablation via Atrial Fibrillation Effect on QualiTy of Life Survey (AFEQT) and EuroQoL EQ-5D-5L questionnaires. All-cause and cardiovascular hospitalisations and cardioversions over 12 months pre-ablation and post-ablation were recorded. Rhythm monitoring included weekly and symptom-driven trans-telephonic monitoring, plus ECG and Holter monitoring at 3, 6 and 12 months. AF burden was defined as the percentage of postblanking tracings with an atrial tachyarrhythmia ≥30 s. Continuous measures across multiple time points were analysed using paired t-tests, and associations between various continuous measures were analysed using independent sample t-tests. Each statistical test used two-sided p values with a significance level of 0.05.ResultsBoth QOL instruments showed significant 12-month improvements across all domains: AFEQT score increased 25.1–37.5 points and 33.3%–50.8% fewer patients reporting any problem across EuroQoL EQ-5D-5L domains. Overall, AFEQT improvement was highly associated with AF burden (p=0.009 for 2DS2-VASc scores at baseline, and higher AF burden following PVI.ConclusionsQOL improved and healthcare utilisation decreased significantly after ablation with a standardised CLOSE protocol. QOL improvement was significantly associated with impairment at baseline and AF burden after ablation.Trial registration numberNCT03062046.

Aims Controversial results have been published regarding the influence of pulmonary vein (PV) anatomical variations on outcomes after pulmonary vein isolation (PVI). However, no data are available on the impact of PV orientation on the long-term success rates of point-by-point PVI. We sought to determine the impact of PV anatomy and orientation on atrial fibrillation (AF)-free survival in patients undergoing PVI using the radiofrequency point-by-point technique. Methods and results We retrospectively included 448 patients who underwent initial point-by-point radiofrequency ablation for AF at our department. Left atrial computed tomography angiography was performed before each procedure. PV anatomical variations, ostial parameters (area, effective diameter, and eccentricity), orientation, and their associations with 24-month AF-free survival were analysed. PV anatomical variations and ostial parameters were not predictive for AF-free survival (all P > 0.05). Univariate analysis showed that female sex (P = 0.025) was associated with higher rates of AF recurrence, ventral-caudal (P = 0.002), dorsal-cranial (P = 0.034), and dorsal-caudal (P = 0.042) orientation of the right superior PV (RSPV), on the other hand, showed an association with lower rates of AF recurrence, when compared with the reference ventral-cranial orientation. On multivariate analysis, both female sex [odds ratio (OR) 1.83, 95% CI 1.15–2.93, P = 0.011] and ventral-caudal RSPV orientation, compared with ventral-cranial orientation, proved to be independent predictors of 24-month AF recurrence (OR 0.37, 95% CI 0.19–0.71, P = 0.003). Conclusion Female sex and ventral-caudal RSPV orientation have an impact on long-term arrhythmia-free survival. Assessment of PV orientation may be a useful tool in predicting AF-free survival and may contribute to a more personalized management of AF.

Aims Unlike in atrial fibrillation ablation, there is a lack of appropriately sized and properly designed studies regarding outflow tract (OT) premature ventricular complex (PVC) ablation outcomes with contact force sensing (CFS) catheters. We aimed to compare the acute success-, complication-, and long-term recurrence rates of manual CFS catheters with traditional irrigated catheters (T) in OT PVC ablation. Methods and results Single-centre, propensity-matched data of 75–75 patients ablated for right-sided OT (RVOT) or left-sided OT (LVOT) PVCs in 2015–17 with CFS or T catheters were compared. Acute success rate, peri-procedural complications, post-procedural daily PVC burden, and long-term recurrence rates were compared on intention-to-treat basis. Acute success rate equalled 80% in both groups, with no difference in force values in the CFS group comparing successful or failed cases [12.0 (8.75–17.0) vs. 16.0 (10.25–22.25) g, P = 0.21]. There were three cases of pseudo-aneurysm and one cardiac tamponade. PVC burden fell significantly from baseline 22 (15–30)% to 2 (0–10)% (P Conclusion Both types of catheters can effectively reduce OT PVC burden with minimal serious complication rates. Ablation with CFS or T catheters gives similar acute- and long-term results.

Aims Our aim was to develop a machine learning (ML)-based risk stratification system to predict 1-, 2-, 3-, 4-, and 5-year all-cause mortality from pre-implant parameters of patients undergoing cardiac resynchronization therapy (CRT). Methods and results Multiple ML models were trained on a retrospective database of 1510 patients undergoing CRT implantation to predict 1- to 5-year all-cause mortality. Thirty-three pre-implant clinical features were selected to train the models. The best performing model [SEMMELWEIS-CRT score (perSonalizEd assessMent of estiMatEd risk of mortaLity With machinE learnIng in patientS undergoing CRT implantation)], along with pre-existing scores (Seattle Heart Failure Model, VALID-CRT, EAARN, ScREEN, and CRT-score), was tested on an independent cohort of 158 patients. There were 805 (53%) deaths in the training cohort and 80 (51%) deaths in the test cohort during the 5-year follow-up period. Among the trained classifiers, random forest demonstrated the best performance. For the prediction of 1-, 2-, 3-, 4-, and 5-year mortality, the areas under the receiver operating characteristic curves of the SEMMELWEIS-CRT score were 0.768 (95% CI: 0.674–0.861; P Conclusion The SEMMELWEIS-CRT score (available at semmelweiscrtscore.com) exhibited good discriminative capabilities for the prediction of all-cause death in CRT patients and outperformed the already existing risk scores. By capturing the non-linear association of predictors, the utilization of ML approaches may facilitate optimal candidate selection and prognostication of patients undergoing CRT implantation.

Patient: Male, 69 Final Diagnosis: Ventricular tachycardia storm post PVI ablation Symptoms: Recurrent premature ventricular contractions at 180–200 bpm rate that progressed into a VT storm Medication: — Clinical Procedure: Radiofrequency PVI ablation Specialty: Cardiology Objective: Unknown ethiology Background: The occurrence of ventricular arrhythmias (VAs), particularly premature ventricular complexes, following pulmonary vein isolation (PVI) is a documented phenomenon, but monomorphic scar-related ventricular tachycardia (VT) following PVI is an unusual phenomenon. In this case report, we present a case of new-onset VA after radiofrequency PVI in a patient with no prior history of sustained VTs. Case Report: Our patient was a 69-year-old man with a history of symptomatic persistent atrial fibrillation, with an apparently structurally normal heart with subtle regional wall motion abnormalities. He underwent radiofrequency directed pulmonary vein isolation ablation. On the night of an uneventful procedure, the patient for the first time experienced a sustained ventricular tachycardia that exacerbated into a VT storm. Each arrhythmia was terminated by cardioversion due to hemodynamic instability. Antiarrhythmic treatment with lidocaine was initiated immediately. The patient settled from sustained ventricular arrhythmia and received further ablation to monomorphic ventricular tachycardia. Conclusions: The incidence of ventricular ectopics after PVI ablation has been previously described, but a sustained monomorphic ventricular storm has not been reported before with RF ablation. We attribute the pathophysiology to an increase in myocardial excitability and/or ventricular autonomic modulation. This is a very rare phenomenon, but any subtle imaging abnormality before planning RF-PVI should be taken into consideration.

Background and Aims. Resynchronization therapy (CRT) improves mortality and induces reverse remodeling in heart failure (HF) patients with reduced ejection fraction and wide QRS. Nonetheless, some patients do not improve despite the optimal medical therapy and right indications for device implantation. Therefore, finding biomarkers suitable for identification of those patients is crucial. Vitamin D plays a classic hormonal role in the regulation of bone metabolism and also has physiological functions in wide range of nonskeletal tissues. Based on recent studies, low levels of vitamin D seem to directly contribute to pathogenesis and worsening of HF. We planned to assess the role of vitamin D levels on clinical outcomes of HF patients undergoing CRT. Methods and Results. We enrolled 136 HF patients undergoing CRT. Total plasma vitamin D levels were measured at baseline and 6 months later. Primary endpoint was 5-year all-cause mortality; secondary endpoint was lack of good clinical response, defined as less than 15% increase of left ventricular ejection fraction after six months. During follow-up, 58 patients reached the primary, and 45 patients reached the secondary endpoint. Vitamin D levels less than 24.13 ng/mL predicted 5-year mortality (p=0.045) and poor clinical response (p=0.03) after adjusting to all significant baseline predictors. Conclusion. Our study showed that vitamin D deficiency has a significant impact in heart failure patients; it is an independent predictor of lack of midterm clinical response and long-term mortality in patients undergoing CRT. Therefore, monitoring vitamin D status of heart failure patients could be of clinical significance.

Abstract: Introduction: Levels of cardiac necroenzymes, high-sensitive troponin (hsTnT) and creatine kinase muscle-brain (CKMB) increase as a result of a myocardial damage following catheter ablation. Aim: To analyze the mid-term alteration of hsTnT and CKMB levels following radiofrequency ablation (RFCA) for atrial fibrillation (AF), atrial flutter (AFlu), AV-nodal reentry tachycardia (AVNRT) and electrophysiological studies (EPS) without ablation. Method: Patients undergoing RFCA for various indications and EPS were consecutively enrolled in our prospective study. Concentrations of hsTnT and CKMB were measured from serial blood samples directly before and after the procedure, 4 and 20 hours later and at 3 months follow-up. Results: Forty-seven patients (10 EPS, 12 AVNRT, 13 AFlu, 12 AF) with mean age of 55 ± 13 were included. hsTnT levels increased significantly in all groups after the procedures, while CKMB changed only in the AF group. hsTnT exceeded the reference value in all patients with ablation and in 80% of patients with EPS 4 hours post-ablation. Peak average hsTnT levels for EPS, AVNRT, AFlu were 24 ± 11, 260 ± 218 and 541 ± 233 ng/L, respectively. The highest hsTnT level was measured in the AF group (799 ± 433 ng/L). We found a positive correlation between hsTnT levels and ablation time after RFCA. Conclusions: The hsTnT levels significantly change after EPS and RFCA, in all patients who underwent ablation, and in 80% of those with EPS had hsTnT positivity in the early post-procedural phase. hsTnT levels depended significantly on the type of the subgroups and correlated with the ablation time. Awareness of those observations is essential to correctly interpret elevated hsTnT levels following RFCA. Orv Hetil. 2019; 160(14): 540–548.

Introduction Stroke is one of the most feared complications during catheter ablation of atrial fibrillation (AF). While symptomatic thromboembolic events are rare, magnetic resonance imaging (MRI) may identify asymptomatic (ie, silent) cerebral lesions (SCLs) following pulmonary vein isolation (PVI) procedures. Methods and Results The REDUCE‐TE Pilot was a prospective multicenter, single‐arm observational study investigating the incidence of SCL in patients with symptomatic paroxysmal AF undergoing PVI with a novel gold‐tip, externally irrigated ablation catheter. After ablation, cerebral diffusion‐weighted MRI and a postablation follow‐up were performed at 1 to 3 days after the ablation procedure. A neurocognitive test was done before and after ablation. The primary study endpoint was the occurrence of one or more new SCLs. Secondary study endpoints included neurocognitive status, procedural success rate, and periprocedural complications including symptomatic thromboembolic events. A total of 104 patients were enrolled (69% male, mean age: 61.5 ± 9.7 years, mean CHA2DS 2‐VASc score: 1.7 ± 1.2). Postprocedural MRI examination was performed in 97 patients, and in nine of them (9.3%; 95% CI: 4.3‐16.9%) a total of 11 SCLs were detected. Univariate analyses did not reveal any significant predictor for new SCLs. Nonsignificant trends were observed for low activated clotting time during ablation and for international normalized ratio value outside the range of 2 to 3 at ablation. There was no evidence of significant deterioration of neurocognitive function after PVI. In four patients, a pericardial tamponade was noted but all patients fully recovered during follow‐up. Conclusions Ablation of AF using a novel gold‐tip, externally irrigated ablation catheter, resulted in SCLs in approximately one out of 10 patients without a measurable effect on neurocognitive function.

Aims Atrial fibrillation (AF) ablation has made huge progress with respect to innovation, efficacy, and safety, however, complications are still present. Recent studies examined various predictors of complications. However, limited data exist regarding the role of a repeat procedure. Our aim was the prospective evaluation of the incidence and predictors of complications related to AF ablation procedures in consecutive patients, including repeat procedures. Methods and results All ablation procedures for AF between January 2013 and December 2015 were analysed in our electrophysiology laboratory. During the study period 1243 procedures were analysed [394 female, median age 62 (55–69)]. Overall complication rate was 6.84%, major complication rate was 2.82%. Major complications were the following: 18 pericardial tamponades; 5 pseudoaneurysms; 1 arteriovenous fistula; 6 thromboembolic cerebrovascular events; 3 pulmonary vein stenosis; and 2 atrioventricular blocks. No atrio-oesophageal fistula or procedure related death occurred. Univariate analysis for overall complications showed that age ≥ 65 years (P = 0.0231), female gender (P = 0.0438), hypertension (P = 0.0488), CHA2DS2-VASc score ≥ 2 (P = 0.0156), and previous AF ablation procedure (P

INTRODUCTION AND OBJECTIVES Cardiac resynchronization therapy (CRT) is beneficial for selected heart failure (HF) patients, although nonresponse to therapy is still prevalent. We investigated a set of novel biomarkers associated with various pathophysiological pathways of HF. Our purpose was to assess their ability to predict clinical outcomes after CRT. METHODS We studied 136 chronic HF patients undergoing CRT. We measured the plasma levels of fractalkine, pentraxin-3, hepatocyte growth factor (HGF), carbohydrate antigen-125, and matrix metalloproteinase-9 before and 6 months after CRT. The primary endpoint of the study was 5-year all-cause mortality, and we considered the absence of 6-month reverse remodelling (defined as at least a 15% decrease in end-systolic volume) as a secondary endpoint. RESULTS Fifty-eight patients died during the 5-year follow-up period and 66 patients were categorized as nonresponders. In multivariable models, only an increased HGF was an independent predictor of both mortality (HR, 1.35; 95%CI, 1.11-1.64; P=.003; per 1 standard deviation increase) and the absence of reverse remodelling (OR, 1.83; 95%CI, 1.10-3.04; P=.01; per 1 standard deviation increase). Applying HGF to the basic multivariable model of both mortality (net reclassification improvement=0.69; 95%CI, 0.39-0.99; P

ObjectivesThe association between obesity and atrial fibrillation (AF) is well-established. We aimed to evaluate the impact of index body mass index (BMI) on AF recurrence at 12 months following catheter ablation using propensity-weighted analysis. In addition, periprocedural complications and fluoroscopy details were examined to assess overall safety in relationship to increasing BMI ranges.MethodsBaseline, periprocedural and follow-up data were collected on consecutive patients scheduled for AF ablation. There were no specific exclusion criteria. Patients were categorised according to baseline BMI in order to assess the outcomes for each category.ResultsAmong 3333 patients, 728 (21.8%) were classified as normal (BMI 2), 1537 (46.1%) as overweight (BMI 25.5–29.0 kg/m2) and 1068 (32.0%) as obese (BMI ≥30.0 kg/m2). Procedural duration and radiation dose were higher for overweight and obese patients compared with those with a normal BMI (p=0.002 and p2led to a 1.2-fold increased likelihood of experiencing recurrent AF at 12-months follow-up as compared with overweight patients (HR 1.223; 95% CI 1.047 to 1.429; p=0.011), while no significant correlation was found between overweight and normal BMI groups (HR 0.954; 95% CI 0.798 to 1.140; p=0.605) and obese versus normal BMI (HR 1.16; 95% CI 0.965 to 1.412; p=0.112).ConclusionsPatients with a baseline BMI ≥30 kg/m2have a higher recurrence rate of AF following catheter ablation and therefore lifestyle modification to target obesity preprocedure should be considered in these patients.

Resumen Introduccion y objetivos La terapia de resincronizacion cardiaca (TRC) es beneficiosa para pacientes seleccionados con insuficiencia cardiaca (IC), aunque la ausencia de respuesta a la terapia es aun prevalente. Se investiga un conjunto de nuevos biomarcadores asociados a varias vias fisiopatologicas de la IC. El proposito fue valorar su capacidad para predecir los resultados clinicos con la TRC. Metodos Se estudio a 136 pacientes con IC cronica y TRC. Se midieron los valores plasmaticos de fractalquina, pentraxina-3, factor de crecimiento hepatocitario (HGF), el antigeno carbohidrato 125 y la metaloproteinasa de matriz 9 tanto antes como 6 meses despues del inicio de la TRC. El objetivo primario del estudio fue la mortalidad por todas las causas a 5 anos, y se considero la ausencia de remodelado inverso a los 6 meses (definido como al menos un 15% de descenso del volumen telesistolico) como un objetivo secundario. Resultados Cincuenta y ocho pacientes fallecieron a lo largo de los 5 anos de seguimiento y 66 pacientes se categorizaron como no respondedores. En modelos multivariables, solo un aumento del HGF resulto un predictor independiente, tanto de mortalidad (HR = 1,35; IC95%, 1,11-1,64; p = 0,003; por cada unidad de incremento de la desviacion estandar) como de ausencia de remodelado inverso (OR = 1,83; IC95%, 1,10-3,04; p = 0,01; por cada unidad de incremento de la desviacion estandar). Aplicando el HGF al modelo basico multivariable tanto de mortalidad (mejora neta de reclasificacion = 0,69; IC95%, 0,39-0,99; p Conclusiones De los biomarcadores investigados, solo el HGF predijo los resultados clinicos despues de la TRC independientemente de otros parametros. Los analisis de reclasificacion mostraron que las mediciones de HGF podrian ser utiles para mejorar la seleccion de pacientes.

Funding Acknowledgements Type of funding sources: None. Background Catheter ablation is the cornerstone for rhythm control in patients with drug-refractory atrial fibrillation (AF). Baseline predictors of AF recurrence after catheter ablation are well established, such as female gender and left atrial enlargement. The role of the spatial relationship between the left superior pulmonary vein (LSPV) and left atrial appendage (LAA) is unknown. Purpose We sought to evaluate whether juxtaposed LSPV and LAA plays a role in AF recurrence after catheter ablation for paroxysmal AF. Methods Consecutive patients, who underwent point-by-point radiofrequency catheter ablation for paroxysmal AF at our hospital between January of 2014 and December of 2017, were enrolled in the study. All patients underwent pre-procedural cardiac CT-angiography (CTA) for the assessment of left atrial (LA) and pulmonary vein (PV) anatomy. Abutting LAA-LSPV was defined as cases when LSPV touched the posterior aspect of LAA (distance less than 2 mm). Results We included 428 patients (60.7 ± 10.8 years, 35.5% female). AF recurrence rate was 33.4% with a median recurrence-free time of 21.2 (IQR = 8.8-43.0) months. In the univariate analysis, female sex (HR = 1.45; 95%CI = 1.04-2.01; p = 0.028), LA volume (HR = 1.01; 95%CI = 1.00-1.01; p = 0.042), and cases when LSPV touched the posterior wall of LAA (HR = 1.53; 95%CI = 1.09-2.14; p = 0.013) were associated with AF recurrence. In the multivariate analysis, female sex (adjusted HR = 1.55; 95%CI = 1.06-2.28; p = 0.024), LA volume (adjusted HR = 1.01; 95%CI = 1.00-1.02; p = 0.028), and abutting LAA-LSPV (adjusted HR = 1.60; 95%CI = 1.13-2.50; p = 0.008) remained significant predictors of AF recurrence. Conclusion Female gender, higher LA volume, and abutting LSPV and LAA predispose patients to have a higher chance for arrhythmia recurrence after catheter ablation for paroxysmal AF.

Objective Pulmonary vein isolation (PVI) is the cornerstone of the interventional treatment of atrial fibrillation (AF). Traditionally, during these procedures the catheters are guided by fluoroscopy, which poses a risk to the patient and staff by ionizing radiation. Our aim was to describe our experience in the implementation of an intracardiac echocardiography (ICE) guided zero fluoroscopic (ZF) ablation approach to our routine clinical practice. Methods We developed a simplified ICE guided technique to perform ablation procedures for AF, with the aid of a 3D electroanatomical mapping system. The workflow was implemented in two phases: (1) the Introductory phase, where the first 16 ZF PVIs were compared with 16 cases performed with fluoroscopy and (2) the Extension phase, where 71 consecutive patients (including repeat procedures) with ZF approach were included. Standard PVI (and redoPVI) procedures were performed, data on feasibility of the ZF approach, complications, acute and 1-year success rates were collected. Results In the Introductory phase, 94% of the procedures could be performed with complete ZF with a median procedure time of 77.5 (73.5–83) minutes. In one case fluoroscopy was used to guide the ICE catheter to the atrium. There was no difference in the complication, acute and 1-year success rates, compared with fluoroscopy guided procedures. In the Extension phase, 97% of the procedures could be completed with complete ZF. In one case fluoroscopy was used to guide the transseptal puncture and in another to position the ICE catheter. Acute success of PVI was achieved in all cases, 64.4% patients were arrhythmia free at 1-year. Acute major complications were observed in 4 cases, all of these occurred in the redo PVI group and consisted of 2 tamponades, 1 transient ischemic attack and 1 pseudoaneurysm at the puncture site. The procedures were carried out by all members of the electrophysiology unit in the Extension phase, including less experienced operators and electrophysiology fellows (3 physicians) under the supervision of the senior electrophysiologist. Consequently, procedure times became longer [90 (75–105) vs 77.5 (73.5–85) min, p = 0.014]. Conclusions According to our results, a ZF workflow of AF ablations can be successfully implemented into the routine practice of an electrophysiology laboratory, without compromising safety and effectivity.

Background. The burden and persistence of atrial fibrillation (AF) have been associated with the presence and extent of left atrial (LA) fibrosis. Recent reports have implicated an association between the extent of LA fibrosis and the outcome of pulmonary vein isolation (PVI). We aimed to analyse the value of an automated scar quantification method in the prediction of success following PVI. Methods. One hundred and nine consecutive patients undergoing PVI for paroxysmal or persistent AF were included in our observational study with a 2-year follow-up. Prior to PVI, patients underwent high-definition LA electroanatomical mapping, and scar burden was quantified by automated software (Voltage Histogram Analysis, CARTO 3, Biosense Webster), then classified into 4 subgroups (Dublin Classes I-IV). Recurrence rates were analysed on and off antiarrhythmic drug therapy (AAD), respectively. Results. The overall success rate was 74% and 67% off AAD at 1- and 2-year follow-up, respectively. Patients with Dublin Class IV had significantly lower success rates ( p = 0.008 , off AAD). Dublin Class IV ( OR = 2.27 , p = 0.022 , off AAD) and the presence of arrhythmia in the blanking period ( OR = 3.28 , p = 0.001 , off AAD) were the only significant predictors of recurrence. The use of AAD did not affect these results. Conclusions. We propose a classification of low voltage areas based on automated quantification by software during 3D mapping prior to PVI. Patients with high burden of low voltage areas (>31% of

Aims To evaluate the safety and effectiveness of pulmonary vein isolation in paroxysmal atrial fibrillation (PAF) using a standardized workflow aiming to enclose the veins with contiguous and optimized radiofrequency lesions. Methods and results This multicentre, prospective, non-randomized study was conducted at 17 European sites. Pulmonary vein isolation was guided by VISITAG SURPOINT (VS target ≥550 on the anterior wall; ≥400 on the posterior wall) and intertag distance (≤6 mm). Atrial arrhythmia recurrence was stringently monitored with weekly and symptom-driven transtelephonic monitoring on top of standard-of-care monitoring (24-h Holter and 12-lead electrocardiogram at 3, 6, and 12 months follow-up). Three hundred and forty participants with drug refractory PAF were enrolled. Acute effectiveness (first-pass isolation proof to a 30-min wait period and adenosine challenge) was 82.4% [95% confidence interval (CI) 77.4–86.7%]. At 12-month follow-up, the rate of freedom from any documented atrial arrhythmia was 78.3% (95% CI 73.8–82.8%), while freedom from atrial arrhythmia by standard-of-care monitoring was 89.4% (95% CI 78.8–87.0%). Freedom fromrepeat ablations by the Kaplan–Meier analysis was 90.4% during 12 months of follow-up. Of the 34 patients with repeat ablations, 14 (41.2%) demonstrated full isolation of all pulmonary vein circles. Primary adverse event (PAE) rate was 3.6% (95% CI 1.9–6.3%). Conclusions The VISTAX trial demonstrated that a standardized PAF ablation workflow aiming for contiguous lesions leads to low rates of PAEs, high acute first-pass isolation rates, and 12-month freedom from arrhythmias approaching 80%. Further research is needed to improve the reproducibility of the outcomes across a wider range of centres. Clinical trial registration: ClinicalTrials.gov, number NCT03062046, https://clinicaltrials.gov/ct2/show/NCT03062046.

Introduction Ablation Index (AI) is a novel catheter-based parameter developed to improve and increase efficacy and safety of Pulmonary Vein Isolations (PVI) in the treatment of Atrial Fibrillation (AF). This method involves the incorporation of contact force, time and power in deliverance of ablation lines. The aim of this study is to evaluate the impact of AI on the AF free burden over one-year post redo ablation for persistent AF. The study evaluates a secondary endpoint in medical management escalations post procedure. Methods A retrospective single centre study of 39 patients (Mater Private Hospital, Dublin) who had redo ablations for persistent AF between the period of Jan 2016 till December 2019. We evaluated and analysed the efficacy of AI on redo PVIs in comparison to conventional established ablation techniques. Both groups were matched for age, gender, and duration of PeAF. Group 1 (17 patients) was the AI group with ablation index intervention and group 2 was the contact force (CF) -guided group with 22 patients. Each cardiologist carried out a minimum of 100 ablations per year to confirm the uniformity of performance. Patient follow-up data was analysed at staged intervals for one-year post procedure. Inclusion criteria are: Patients must have had one prior PVI procedure for PeAF, complete follow up data available and all procedures completed using the Carto 3D Mapping System. Statistical analysis was carried out using SPSS (IBM SPSS Statistic Version 26). A Kaplan Meier graph was generated to evaluate the AF free interval. All continuous variables were expressed as the mean ± SD and Students T Test to was applied to give the significant differences for continuous variables. Results Patient characteristics are demonstrated in Table 1. There were no significant differences in age, sex, weight, height, CHADVASC or anti-arrythmia agents, which indicated similar patient profile in each cohort. Pulmonary vein reconnections at redo PVI procedure were comparable at 100% in the AI group and 86% in the CF group (p = 0.1). Freedom from AF burden was (mean 8.72 ± 4.33 months) in CF group Versus (mean 9.35 ± 4.1 months) in AI guided ablation (p=0.71) (figure 1). The AI group demonstrated greater numbers of patients in whom antiarrhythmic therapy could be deescalated over one year (AI, n=11/17, 65% Vs. CF, n=2/22, 9% with p=0.01) while fewer patients underwent escalation of their antiarrhythmic therapy (AI n=2/17, 12% vs CF n=6/22, 27% p= 0.03) (table 1). Conclusion This is the first study to analyse the outcomes of ablation index on repeat PVI procedures. Despite no significant difference in AF recurrence outcomes demonstrated in this study, there was a significant difference in the medical de-escalation in favour of the use of the AI over the short term follow up period. This may reflect effective ablation lesions. A longer-term analysis would be recommended to determine the efficacy of AI use in PeAF redo procedures.

Introduction. Growing evidence suggests that fibrotic changes can be observed in atrial fibrillation (AF) in both atria. Quantification of the scar burden during electroanatomical mapping might have important therapeutic and prognostic consequences. However, as the current invasive treatment of AF is focused on the left atrium (LA), the role of the right atrium (RA) is less well understood. We aimed to characterize the clinical determinates of the RA low-voltage burden and its relation to the LA scaring. Methods. We have included 36 patients who underwent catheter ablation for AF in a prospective observational study. In addition to LA mapping and ablation, high-density RA bipolar voltage maps (HD-EAM) were also reconstructed. The extent of the diseased RA tissue (≤0.5 mV) was quantified using the voltage histogram analysis tool (CARTO®3, Biosense Webster). Results. The percentage of RA diseased tissue burden was significantly higher in patients with a CHA2DS2-VASc score ≥ 2 p=0.0305, higher indexed LA volume on the CTA scan and on the HD‐EAM (p=0.0223 and p=0.0064, respectively), or higher indexed RA volume on the HD‐EAM p=0.0026. High RA diseased tissue burden predicted the presence of high LA diseased tissue burden (OR = 7.1, CI (95%): 1.3–38.9, p=0.0145), and there was a significant correlation of the same (r = 0.6461, p<0.0001). Conclusions. Determining the extent of the right atrial low-voltage burden might give useful clinical information. According to our results, the diseased tissue burden correlates well between the two atria: the right atrium mirrors the left atrium.

Background/Introduction The ‘CLOSE’ protocol, incorporating standardized ablation index (AI) targets in conjunction with defined inter-tag distance (ITD) has been shown to improve the acute and long-term success of pulmonary vein isolation (PVI) when treating paroxysmal atrial fibrillation (PAF). The reproducibility and learning curve for this protocol has not been studied. Purpose To assess the acute and long-term efficacy of CLOSE PVI across multiple operators (n = 37) in the 17-centre European study ‘VISTAX’. Methods 329 patients with PAF (61.8% male, 61.3 ± 10.1 years) underwent PVI according to the CLOSE protocol, with target AI values for each lesion of ≥400 on the posterior wall and ≥550 on the anterior wall, and target ITD of ≤6mm. Each 3-dimensional electroanatomic map was evaluated at a core lab where adherence to each of these criteria was assessed. 281/329 patients (85.1%) fulfilled all standardized workflow requirements and were adjudicated as having their PVI per-protocol (PP). First pass PVI and acute effectiveness (adenosine-proof first pass PVI at 30-minute challenge) were recorded. Clinical effectiveness was assessed as freedom from atrial arrhythmia recurrence through 12 months recorded via transtelephonic monitoring (weekly and symptomatically), in addition to holter and electrocardiogram monitoring during 3,6,12 month follow up visits. Learning curve analysis was evaluated on all investigators. Results First pass PVI rates were similar in the overall (86%) and PP cohorts (85%), as was acute effectiveness (82% in both cohorts). Freedom from atrial arrhythmia at 12 months too was identical for both cohorts (79%). Total procedure time and total ablation time decreased by an average 8 minutes and 10 minutes respectively after the first procedure and then showed further steady decreases over the number of ablations performed by the investigator (Figure). The procedural efficiencies and clinical success were reproducible across different centers. No significant deviations were found from individual sites. Conclusion The standardized CLOSE workflow is reproducible across centres, and is ‘forgiving’ without impacting on high efficacy of almost 80%. The learning curve is short, suggesting that the excellent clinical results can be replicated widely and easily. Abstract Figure. Learning Curves- Procedure & Ablation

Introduction Assessment of left atrial function via transthoracic echocardiography (TTE) is performed most commonly by measuring the transmitral A wave in sinus rhythm. Left atrial (LA) fibrosis plays an important role in the pathogenesis and perpetuation of Atrial Fibrillation (AF). It may be identified by bipolar voltage (BiV) mapping, which can easily be performed at the beginning of a Pulmonary Vein Isolation (PVI) procedure. The relationship between the degree of LA fibrosis, characterised with mapping, and LA function, determined by echocardiography, has not previously been elucidated. Methods Patients were enrolled in a project to evaluate the degree of fibrosis during PVI procedures. Pre-procedure TTEs of those presenting in sinus rhythm were assessed and the transmitral A wave was measured and compared to the degree of scarring seen. The high density electroanatomic maps (HD-EAMs) created during the PVIs were analysed using a novel VHA algorithm after the procedure. All points with voltages < 0.5mV were defined to have electrical scar. Patients were classified into 4 quartiles based on the levels of scar seen (Figure 1). Results 39 patients were included in the evaluation. Average age was 60.6 +/- 13.2 years. 32 (82.0%) of the patients were male. Mean CHADS2VASc score was 1.5. The mean percentage of scar was calculated as 19.6 +/- 15.9%. The average A wave was 0.62 +/- 0.18 ms-1. Pearson’s correlation coefficient showed no relationship between LA scar and either A wave velocities (r = 0.26, p = 0.11) or E:A ratio (r=-0.02, p = 0.91). A significant correlation between A wave velocity and CHADS2VASc was observed (r = 0.49, p = 0.001). Conclusion Our study demonstrates no relationship between degree of LA scarring and reduced LA function on TTE as assessed by the A wave. It has been established that structural remodelling in AF (such as atrial dilatation) may occur independently of the electrical remodelling. A potential explanation for our findings is that the electrical scarring in AF, which results in alterations in refractory periods, precedes the negative remodelling which ultimately results in reduced atrial function. This hypothesis would need to be further evaluated in larger studies. Abstract Figure 1

Background/Introduction The use of a standardized ‘CLOSE’ ablation workflow for pulmonary vein isolation (PVI), with defined inter-tag distance (ITD) with targeted ablation index (AI) values, has been shown in single centre reports to result in good outcomes. The effect of this approach on patients’ quality of life (QoL) has not been studied. Purpose To evaluate the effects of paroxysmal atrial fibrillation (PAF) ablation by the CLOSE workflow on QoL and symptomatic AF reduction in the multicenter VISTAX study. Methods 329 patients with PAF (61.5% male, 61.3 ± 10.1 year) were treated at 17 European centres by point-by-point radiofrequency ablation using the CLOSE protocol to achieve PVI. An ITD ≤6mm and AI values of ≥400 on the posterior wall and ≥550 on the anterior wall were targeted. The AI value on the posterior wall was lowered as per investigator discretion in case of safety concerns. Patients were monitored for atrial arrhythmia recurrences via weekly and symptom-activated transtelephonic monitoring (TTM), for 12 months post procedure. Patients completed an Atrial Fibrillation Effect on Quality-of-life (AFEQT) questionnaire at their baseline and 12-month follow up visits. Results Majority (83.3% [274/329]) of patients experienced freedom from symptomatic atrial recurrence through 12 months. Of the 70 documented recurrences, 34 (49%) were documented by trans-telephonic monitoring only. All domains captured on the AFEQT questionnaire showed improvement with the overall score improving by 25.7, which exceeded the threshold of clinically meaningful improvement (±5) (Table). Patient reported most improvements in PAF control and symptoms relieved. The overall AFEQT score improvement was seen both in patients with or without documented atrial arrhythmia recurrence, with improvement by 21.5 and 26.8, respectively. Conclusion PAF ablation using a standardized CLOSE workflow resulted in consistent improvements in QoL. The improved QoL was observed regardless of atrial arrhythmia recurrence likely reflecting the low residual arrhythmia burden in patients with documented recurrence identified only on TTM. AFEQT Scores Through 12 Months AFEQT Domain Baseline 12 Months Change from Baseline* Daily Activities 59.2 85.3 26.0 Treatment Concerns 62.2 88.1 26.0 Controlling PAF 50.2 87.8 37.5 Symptoms 63.7 89.0 25.1 Symptoms Relieved 52.0 88.4 36.3 Overall AFEQT Score 61.3 87.2 25.7 *only includes patients who completed both baseline and 12 month AFEQT questionnaire

Aims There are previous studies on quality of life (QoL) in cardiac resynchronization therapy (CRT) patients; however, there are no data with the short EuroQol-five dimensions (EQ-5D) questionnaire predicting outcomes. We aimed to assess the predictive role of baseline QoL and QoL change at 6 months after CRT with EQ-5D on 5-year mortality and response. Methods and results In our prospective follow-up study, 130 heart failure (HF) patients undergoing CRT were enrolled. Clinical evaluation, echocardiography, and EQ-5D were performed at baseline and at 6 months of follow–up, continued to 5 years. Primary endpoint was all-cause mortality at 5 years. Secondary endpoints were (i) clinical response with at least one class improvement in New York Heart Association without HF hospitalization and (ii) reverse remodelling with 15% reduction in left ventricular end-systolic volume at 6 months. Fifty-four (41.5%) patients died during 5 years, 85 (65.3%) clinical responders were identified, and 63 patients (48.5%) had reverse remodelling. Baseline issues with mobility were associated with lower response [odds ratio (OR) 0.36, 95% confidence interval (CI) 0.16–0.84; P = 0.018]. Lack of reverse remodelling correlated with self-care issues at baseline (OR 0.10, 95% CI 0.01–0.94; P = 0.04). Furthermore, self-care difficulties [hazard ratio (HR) 2.39, 95% CI 1.17–4.86; P = 0.01) or more anxiety (HR 1.51, 95% CI 1.00–2.26; P = 0.04) predicted worse long-term survival. At 6 months, mobility (HR 3.95, 95% CI 1.89–8.20; P

AIMS: Therapy with an implantable cardioverter defibrillator (ICD) is established for the prevention of sudden cardiac death (SCD) in high risk patients. We aimed to determine the effectiveness of primary prevention ICD therapy by analysing registry data from 14 centres in 11 European countries compiled between 2002 and 2014, with emphasis on outcomes in women who have been underrepresented in all trials. METHODS AND RESULTS: Retrospective data of 14 local registries of primary prevention ICD implantations between 2002 and 2014 were compiled in a central database. Predefined primary outcome measures were overall mortality and first appropriate and first inappropriate shocks. A multivariable model enforcing a common hazard ratio for sex category across the centres, but allowing for centre-specific baseline hazards and centre specific effects of other covariates, was adjusted for age, the presence of ischaemic cardiomyopathy or a CRT-D, and left ventricular ejection fraction ≤25%. Of the 5033 patients, 957 (19%) were women. During a median follow-up of 33 months (IQR 16-55 months) 129 women (13%) and 807 men (20%) died (HR 0.65; 95% CI: [0.53, 0.79], P-value

Background Cardiac resynchronization therapy (CRT) in chronic heart failure has been shown to improve mortality and morbidity. However, comprehensive data are not available as concerns how circulating biomarkers reflecting different organ functions, such as serum uric acid, blood urea nitrogen (BUN), albumin, cholesterol, or various liver enzymes, change over time as a consequence of CRT. The aim of this prospective study was to overview these possible changes. Methods A total of 20 routine laboratory parameters were measured in 122 control subjects and in 129 patients with chronic heart failure before CRT, 6 months, and 2 years later. Results The levels of serum uric acid [before: 432 (331–516) mmol/L, 6-month: 372 (304–452) mmol/L, 2-year: 340 (290–433) mmol/L; p

Background: Coronary artery ectasia (CAE) is defined as a diffuse dilatation of the diameter of the ectatic segment of the coronary artery, 1.5 times greater than that of the adjacent segment. The Tp-Te interval, P-wave and QTc dispersions are relatively new electrocardiographic markers associated with an increased risk of developing arrhythmias. Despite CAE increasing in prevalence in recent years, there is a sparsity of data available about its arrhythmogenic effect. The aim of the study was to evaluate QTc, P-wave dispersion and Tp-Te and Tp-Te/QT ratio in patients with CAE. Methods: A retrospective comparative study was designed for consecutive age- and sex-matched patients. Twenty patients with isolated CAE (group 1) and 20 control subjects (group 2), with normal coronary arteries, were included. All patients presented with chest pain and coronary angiogram was indicated. Outcome measures included Tp-Te interval, Tp-Te/QT ratio, QTc dispersion and P-wave dispersion. Measurement of electrocardiogram (ECG) parameters was conducted using standardized digital online software. Descriptive and inferential statistics were performed. Results: Mean Tp-Te (95.5 ± 9.01 ms) and Tp-Te/QT ratio (0.22 ± 0.02) were significantly prolonged in CAE group (Tp-Te: 84 ± 5.62 ms, P = 0.00009; Tp-Te/QT ratio: 0.20 ± 0.01, P = 0.00004). In addition, QTc (31.2 ± 3.71 ms) and P-wave dispersion (31.9 ± 5.46 ms) were significantly increased in comparison to the control group (QTc: 27.6 ± 2.82 ms, P = 0.00532 and 20 ± 3.77 ms, P = 0.00003 respectively). However, there was no difference in ventricular activation time (VAT) between groups. Conclusions: CAE ECGs were found to be associated with increased Tp-Te, Tp-Te/QT ratio, QTc intervals and P-wave dispersions. This may suggest that CAE existence has a pro-arrhythmogenic nature. Cardiol Res. 2017;8(6):280-285 doi: https://doi.org/10.14740/cr631w

Background Cardiac Resynchronization Therapy (CRT) has well-known beneficial effects in patients with advanced heart failure, reduced ejection fraction and wide QRS complex. However, mortality rates still remain high in this patient population. Therefore, precise risk stratification would be essential, nonetheless, the currently available risk scores have several shortcomings which hamper their utilization in the everyday clinical practice. Purpose Accordingly, our objective was to design and validate a machine learning based risk stratification system to predict 2-year and 5-year mortality from pre-implant parameters of patients undergoing CRT implantation. Methods We trained two models separately to predict 2-year (model 1) and 5-year mortality (model 2). As training cohort of model 1 we used 1678 patients (67±10 years, 1251 [75%] males) undergoing CRT implantation. From this population, 1320 patients (66±10 years, 1005 [76%] males) also completed 5-year follow-up and they served as the training cohort for model 2. Forty-seven pre-implant parameters (demographics, cardiovascular risk factors and clinical characteristics) were used to train the models. Our models were designed in a way to tolerate missing values. Among non-linear classifiers, random forest demonstrated the best performance. We validated our models, along with the Seattle Heart Failure Model (SHFM), VALID-CRT risk score and EAARN score on an independent cohort of 136 patients (66±10 years, 110 [81%] males). Based on the predicted probability of survival, patients were split into quartiles and survival was plotted via Kaplan-Meier (KM) curves. Results There were 358 (21%) deaths in the 2-year, 697 (53%) deaths in the 5-year training cohort. In the validation cohort, there were 30 (22%) deaths at 2 years and 58 (43%) deaths at 5 years after CRT implantation. For the prediction of 2-year mortality, the Area Under the Receiver-Operating Characteristic Curve (AUC) for model 1 was 0.77 (95% CI: 0.67–0.87; p=0.002), for SHFM was 0.54 (95% CI: 0.39–0.69; p=0.006), for EAARN was 0.57 (95% CI: 0.46–0.68, p=0.002), and for VALID-CRT was 0.62 (95% CI: 0.52–0.71; p=0.002). To predict 5-year mortality, the AUC for model 2 was 0.85 (95% CI: 0.78–0.91; p=0.001), for SHFM was 0.62 (95% CI: 0.51–0.74; p=0.003), for EAARN was 0.61 (95% CI: 0.51–0.70, p=0.002), for VALID-CRT was 0.65 (95% CI: 0.56–0.74; p=0.002). The AUCs of the machine learning based models were significantly higher than the AUCs of the pre-existing scores (DeLong test, all p Conclusion Our results indicate that machine learning algorithms can outperform the already existing linear model based scores. By capturing the non-linear association of predictors, the utilization of these state-of-the-art approaches may facilitate optimal candidate selection and prognostication of patients undergoing CRT implantation.

Atrial fibrillation (AF), is the most common sustained arrhythmia and is associated with a substantial increase in morbidity and mortality. Several studies have demonstrated sex-related differences in various aspects, including age at diagnosis, clinical manifestations, management and prognosis. These dissimilarities may dictate different approaches to management and could translate to differences in outcomes. However, similarly to other cardiovascular therapies, there may be a tendency to treat females more conservatively and less aggressively than male patients. The use of oral anticoagulants, for example, is lower in female patients with AF. Electrical cardioversion is less often used. Likewise, despite higher rates of adverse reactions to antiarrhythmic drugs in women, they are less likely to undergo catheter ablations, a well-established therapeutic approach to symptomatic patients with recurrences of AF. In this article, we review sex related dissimilarities in patients with AF. In addition, we discuss various treatment options, and specifically refer to differences in access of treatment, success rates, and potential treatment-related complications. ispartof: EUROPACE vol:21 issue:5 pages:690-697 ispartof: location:England status: published

Changes in the levels of serum creatinine and N-terminal of prohormone brain natriuretic peptide (NT-proBNP) are useful risk markers after cardiac resynchronization therapy (CRT). The diagnostic value of changes in serum uric acid levels has been established in chronic heart failure, but no data are available on the prognostic value of hyperuricemia in a CRT population.We measured markers of renal function [creatinine, blood urea nitrogen (BUN) and uric acid] and NT-proBNP levels of 129 heart failure patients undergoing CRT in a prospective, observational study. The 5-year all-cause mortality and the 6-month clinical response (≥ 15% increase in the left ventricular ejection fraction) were considered as study end points.In multivariable analyses, the uric acid was found to be a statistically significant predictor of the outcome. Uric acid levels exceeding 386 mmol/L before CRT increased the chances of mortality [n = 55, hazard ratio = 2.39 (1.30-4.39), p 0.01] and poor clinical response [n = 37, odds ratio = 2.89 (1.22-6.87), p = 0.01] independently of serum NT-proBNP and other factors.Elevated uric acid concentrations in patients with CRT are associated with an increased risk of mortality and poor clinical response independently of the NT-proBNP levels and other relevant clinical factors.

Left atrial (LA) fibrosis plays an important role in the pathogenesis and perpetuation of atrial fibrillation (AF). It may be identified by bipolar voltage (BiV) mapping, but quantification of fibrosis which previously relied on visual estimation of scar has been shown to be inaccurate. Our aim was to use a novel automated voltage histogram analysis (VHA) tool to quantify LA scar burden accurately in patients with AF. LA voltage was assessed in 100 consecutive patients undergoing first pulmonary vein isolation (PVI) for paroxysmal or persistent AF using a circular multielectrode catheter to create high-density LA BiV maps which were analysed using the VHA tool after the procedure. High-density electro-anatomic maps took 10 min to create and contained a median of 1049 points. The VHA algorithm accurately quantified the burden of Diseased LA Tissue (≤ 0.5 mV) and Dense LA Scar (≤ 0.2 mV) with a median of 17.8% and 3.5% respectively. A quartile classification was applied based on diseased LA tissue burden. Patients in class IV with the highest diseased LA burden were older (p

Electroanatomical mapping is a useful tool during the ablation of atrial fibrillation. Respiratory movement might influence the mapping accuracy and merging. This study aims to investigate the effect of respiratory gating on the accuracy of magnetic-field-based electroanatomical mapping under spontaneous respiration. Fifty-one consecutive patients (35 male, aged 30–78 years) who underwent left atrial radiofrequency catheter ablation due to atrial fibrillation were included. Electroanatomical mapping was performed with CARTO 3 System under conscious sedation. Respiratory gating was achieved with the AccuResp algorithm (Biosense Webster). Average surface match and maximum distance of the pre-acquired and electroanatomical maps, as well as left atrial volume, were recorded with and without respiratory gating after merging. The average surface match of the electroanatomical map with the left atrial reconstruction was significantly better with respiratory gating than without using the algorithm (3.81 ± 1.09 vs 4.11 ± 1.61 mm, p = 0.0119). It was not dependent of the rhythm during mapping or the image modality used for left atrial reconstruction. The maximal distance between the two maps did not depend on the use of the algorithm (19.81 ± 6.24 mm for gated and 20.87 ± 7.99 mm for non-gated, p = 0.3161). Left atrial volume of the map was significantly lower when using the respiratory compensation module (106.3 ± 31.6 vs 127.0 ± 36.4 ml, p

Catheter ablation is a proven therapy of focal atrial tachycardia. However limited information is available about the additional value of electroanatomical over conventional mapping methods for this specific arrhythmia.Consecutive catheter ablation procedures of FAT were analyzed in two cardiology centres. Only conventional mapping was used in 30 of the 60 procedures whereas additionally CARTO mapping was performed in another 30 procedures. Acute, six-month success rate, and procedural data were analyzed.Localization of ectopic foci is congruent with previously published data. There was no statistically significant difference between procedure time and fluoroscopy time using additionally CARTO mapping, compared to conventional mapping only. Acute success rate was higher in procedures guided by CARTO mapping than in procedures based on conventional mapping (27/30 vs. 18/30, p = 0.0081). During the 6-month follow-up period there was a better outcome (p = 0.045) in case of CARTO guided procedures (success: 11 cases, partial success: 12 cases, failure: 4 cases) compared to conventional mapping (success: 4 cases, partial success: 18 cases, failure: 7 cases).Catheter ablation of focal atrial tachycardias using the CARTO electroanatomical mapping system seems to provide higher acute and 6-month success rate compared to ablation using conventional mapping methods only.

BACKGROUND: Despite significant improvements in cardiac output and functional capacity with cardiac resynchronization therapy (CRT), incidence of sudden cardiac death still remains high. Reversal of physiological myocardial activation sequence during epicardial pacing increases the transmural dispersion of repolarization (TDR). The aim of this study was to compare the effects of endocardial and epicardial biventricular pacing on repolarization parameters in the same patient group. METHODS: Seven patients who had transseptal endocardial left ventricle (LV) lead placement, in whom epicardial CRT had failed due to coronary sinus (CS) lead dislodgement after successful implantation, were admitted to the study. LV endocardial leads were implanted through the inter-atrial septum in a lateral position. ECGs were scanned before and after successful epicardial and endocardial biventricular pacing and analyzed using digital callipers. ECG markers of TDR (TpTe and TpTe/QT ratio) were measured and compared. RESULTS: Baseline QRS durations (161.7+/-15.9 vs 162.2+/-17.8 ms, p = 0.95), TpTe values (107.1+/-20.5 vs 108.5+/-17.6 ms, p = 0.89) and TpTe/QT ratios (0.24+/-0.05 vs 0.24+/-0.03, p = 0.88) were similar before epicardial and endocardial CRT. QRS interval reduction was similar (-28.3+/-11.6 vs -29.1+/-11.4 ms, p = 0.89) in both groups. Compared to transseptal endocardial CRT, epicardial CRT was associated with a significant increase in TpTe (17.1+/-19.5 vs -12.6+/-18.9 ms, p = 0.01) and TpTe/QT ratio (0.03+/-0.04 vs -0.02+/-0.03, p = 0.04). CONCLUSION: Transseptal LV endocardial pacing is associated with significant reduction in TDR characteristics compared to epicardial pacing in CRT. Further studies are warranted to determine whether these effects may contribute to reduction of arrhythmias in patients with CRT. This article is protected by copyright. All rights reserved.

Aims Data on longer right to left ventricular activation delay (RV-LV AD) predicting clinical outcome after cardiac resynchronization therapy (CRT) by left bundle branch block (LBBB) are limited. We aimed to evaluate the impact of RV-LV AD on N-terminal pro–B-type natriuretic peptide (NT-proBNP), ejection fraction (EF), and clinical outcome in patients implanted with CRT, stratified by LBBB at baseline. Methods and results Heart failure (HF) patients undergoing CRT implantation with EF ≤ 35% and QRS ≥ 120 ms were evaluated based on their RV-LV AD at implantation. Baseline and 6-month clinical parameters, EF, and NT-proBNP values were assessed. The primary endpoint was HF or death, the secondary endpoint was all-cause mortality. A total of 125 patients with CRT were studied, 62% had LBBB. During the median follow-up of 2.2 years, 44 (35%) patients had HF/death, 36 (29%) patients died. Patients with RV-LV AD ≥ 86 ms (lower quartile) had significantly lower risk of HF/death [hazard ratio (HR): 0.44; 95% confidence interval (95% CI): 0.23–0.82; P = 0.001] and all-cause mortality (HR: 0.48; 95% CI: 0.23–1.00; P = 0.05), compared with those with RV-LV AD < 86 ms. Patients with RV-LV AD ≥ 86 ms and LBBB showed the greatest improvement in EF (28–36%; P

Aims The low lymphocyte counts and high neutrophil leucocyte fractions have been associated with poor prognosis in chronic heart failure. We hypothesized that the baseline ratio of the neutrophil leucocytes to the lymphocytes (NL ratio) would predict the outcome of chronic heart failure patients undergoing cardiac resynchronization therapy (CRT). Methods and results The qualitative blood counts and the serum levels of N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) of 122 chronic heart failure patients and 122 healthy controls were analysed prospectively in this observational study. The 2-year mortality was considered as primary endpoint and the 6-month reverse remodelling (≥15% decrease in the end-systolic volume) as secondary endpoint. Multivariable regression analyses were applied and net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were calculated. The NL ratio was elevated in chronic heart failure patients when compared with the healthy controls [2.93 (2.12–4.05) vs. 2.21 (1.64–2.81), P < 0.0001]. The baseline NL ratio exceeding 2.95 predicted the lack of the 6-month reverse remodelling [n = 63, odds ratio = 0.38 (0.17–0.85), P = 0.01; NRI = 0.49 (0.14–0.83), P = 0.005; IDI = 0.04 (0.00–0.07), P = 0.02] and the 2-year mortality [n = 29, hazard ratio = 2.44 (1.04–5.71), P = 0.03; NRI = 0.63 (0.24–1.01), P = 0.001; IDI = 0.04 (0.00–0.08), P = 0.02] independently of the NT-proBNP levels or other factors. Conclusion The NL ratio is elevated in chronic heart failure and predicts outcome after CRT. According to the reclassification analysis, 4% of the patients would have been better categorized in the prediction models by combining the NT-proBNP with the NL ratio. Thus, a single blood count measurement could facilitate the optimal patient selection for the CRT.

The authors present the history of a 62-year-old man on continuous rivaroxaban therapy who was scheduled for pulmonary vein isolation due to persistent atrial fibrillation. Preoperative transesophageal echocardiography detected the presence of left atrial appendage thrombus. Thrombophilia tests showed that the patient was heterozygous carrier of the methylene-tetrahydrofolate reductase gene mutation. The authors hypothesized that a direct thrombin inhibitor might exert a more appropriate effect against thrombosis in this case and, therefore, a switch to dabigatran was performed. After two months of anticoagulation with the direct thrombin inhibitor and folic acid supplementation the thrombus resolved. The authors underline that thrombus formation may develop in atrial fibrillation even if the patient is adequately treated with rivaroxaban. This case suggests, that methylene-tetrahydrofolate reductase gene mutation may modulate the efficacy of direct Xa factor inhibitors. According to this case history, dabigatran may be an effective therapeutic option in resolving established thrombus. Orv. Hetil., 2016, 157(4), 154–156.

Background Patients with atrial fibrillation (AF) frequently have atrial scarring characterised by discrete regions of low voltage. Pre-existing left atrial scarring is an independent predictor of pulmonary vein isolation (PVI) failure. Novel mapping algorithms have also been developed to assess the degree of atrial fibrosis. This may be expressed as a percentage of the total left atrial (LA) volume mapped. In addition to the electrical remodelling seen, structural remodelling occurs, with dilatation and reduced function. The most accurate determinant of LA function is debated, but the most frequently used method is transmitral A Wave velocity on pulsed-wave Doppler. The relationship between LA function and electrical changes seen in AF has not been defined. Methods This was a single centre observational study. Left atrial voltage maps were created in patients undergoing PVI for the first time in the Mater Private Hospital between August 2016 and April 2017. LA voltage maps were initially created with a Lasso catheter with some further points taken with a Smarttouch ablation catheter (both Biosense Webster, Diamond Bar, California). Voltage greater than 0.5 mV was accepted as normal tissue and voltages Results Out of 96 patients who had undergone PVI, only 24 were found to have had sinus rhythm on pre-procedural echo. The mean age was 63.5 (standard deviation or SD 10.6) years. 66% of the group were men. 58% had paroxysmal AF. The mean amplitude of the A-wave in the study was 0.61 (SD 0.16) ms-1. An average of 1269.7 (SD 857.0) mapping points were taken. The mean LA percentage scar was 25.1 (SD 20.3) %. Using linear regression, adjusted for age at time of procedure, there was a significant negative association between a wave (in ms-1) and % LA scar (Beta coefficient -72.44, 95% CI -122.99 to -21.88, p=0.007). Using pairwise correlation, the correlation coefficient between LA scar and A wave was -0.38, p=0.06. Conclusion Our study found an inverse correlation between transmitral A wave and degree of left atrial scarring when LA function was adjusted for patient age, indicating that LA electrical remodelling as measure by percentage scar is associated with decreased LA function in patients with AF. However, there were only 24 patients in this study and ongoing research with more patients is warranted to further substantiate this.

Lead dislocations of pacemaker systems are reported in all and even in high-volume centers. Repeated procedures necessitated by lead dislocations are associated with an increased risk of complications. We investigated a minimal invasive method for right atrial and ventricular lead repositioning. The minimal invasive method was applied only when passive fixation leads were implanted. During the minimal invasive procedure, a steerable catheter was advanced through the femoral vein to move the distal end of the lead to the appropriate position. Retrospective data collection was conducted in all patients with minimal invasive and with conventional method, at a single center between September 2006 and December 2012. Forty-five minimal invasive lead repositionings were performed, of which eight were acutely unsuccessful and nine electrodes re-dislocated after the procedure. One hundred two leads were repositioned with opening of the pocket during the same time, including the ones with unsuccessful minimal invasive repositionings. One procedure was acutely unsuccessful in this group and four re-dislocations happened. A significant difference of success rates was noted (66.6% vs. 95.1%, p = 0.001). One complication was observed during the minimal invasive lead repositionings (left ventricular lead microdislodgement). Open-pocket procedures showed different types of complications (pneumothorax, subclavian artery puncture, pericardial effusion, hematoma, fever, device-associated infection which necessitated explantation, atrial lead dislodgement while repositioning the ventricular one, deterioration of renal function). The minimal invasive method as a first alternative is safe and feasible. In those cases when it cannot be carried out successfully, the conventional method is applicable.

Cardiac arrest causes generalized ischemia/hypoxia, and subsequent resuscitation inflicts reperfusion injury, the pathology of which is not fully understood. Moreover, predicting the prognosis of comatose, post-cardiac-arrest patients is a complex clinical challenge. We hypothesized that the extent of complement activation might be a reliable predictor of mortality in this population. Forty-six comatose cardiac arrest patients were enrolled into our prospective cohort study, conducted in a tertiary care university clinic. All subjects were cooled to 32-34 degrees C body temperature for 24 hours and then, allowed to rewarm to normothermia. All patients underwent diagnostic coronary angiography. On admission, at 6 and at 24 hrs, blood samples were taken from the arterial catheter. In these, complement products (C3a, C3, C4d, C4, SC5b9, and Bb) were measured by ELISA in blood samples. Patients were followed-up for 30 days; 22 patients (47.8%) died by the end of this period. We observed that complement activation (determined as the C3a to C3 ratio) was higher in non-survivors than in survivors at each time point. In the multivariate Cox regression analysis, the C3a/C3 ratio determined 24 hours after the initiation of therapeutic hypothermia predicted 30-day mortality regardless of age, sex, and the APACHE II score. Complement activation occurs in post-cardiac arrest patients, and its extent correlates with 30-day survival. The C3a/C3 ratio might prove useful for estimating the prognosis of comatose post-cardiac-arrest patients. This article is protected by copyright. All rights reserved.

Background After catheter ablation there is often a discrepancy between acute and chronic success rates. We aimed to evaluate major determinants for lesion quality and understand different manifestations of lesion structures. Methods In a canine thigh muscle model radiofrequency (RF) current was delivered for 60 seconds at 30 W (n = 39) or 50 W (n = 18) with 15-g contact force. A second-generation 12-hole gold open irrigation catheter (SGIT) and a first-generation six-hole platinum-iridium catheter (FGIT; Biotronik, Berlin, Germany) were used. Electrode and tissue temperatures (at the surface and 3.5-mm and 7-mm depth) were recorded and lesion dimensions were measured. Lesions with steam pops were excluded. Histological examination was performed to evaluate homogeneity of the lesions. Inhomogeneity was defined as a visual multiband lesion pattern indicating different histological characteristics. Results In total 57 lesions were created. Seventeen lesions were excluded (steam pops) and 40 lesions were analyzed. A total number of 11 homogeneous and 29 inhomogeneous lesions were identified. Using the SGIT catheter 16.7% of the lesions was homogeneous and 83.3% inhomogeneous; for FGIT it was 43.8% and 56.2% (P = 0.065), respectively. Homogeneous lesions had lower volumes as compared to inhomogeneous lesions (514.0 ± 198.8 vs 914.8 ± 399.1 mm, P = 0.003). Multiple logistic regression analysis indicated that the SGIT catheter is a significant predictor for inhomogeneous lesions (odds ratio 6.5, 95% confidence interval 1.1–38.8; P = 0.040) independent from power setting and flow rate. Conclusions The development of inhomogeneous lesions after acute RF ablation is associated with higher lesion volumes and the use of the second-generation irrigation gold-tip catheter.

Persistent left superior vena cava is a rarely seen anomaly but it may be an arrhythmogenic source for paroxysmal atrial fibrillation. Furthermore, the complex anatomicregion between the left superior vena cava and the pulmonary veins may leads to misinterpretation of the pulmonary vein recordings during atrial fibrillation ablation. Approaches that might be helpful to overcome these problems are discussed in this case report.