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Aim: We aimed to study gender-specific differences in patients who underwent left atrial appendage closure (LAAC). Materials & methods: A total of 201 consecutive patients who underwent LAAC were enrolled. The EQ-5D-3L questionnaire was employed before and 3 months post-LAAC to study the quality of life. Results: Women had a higher score for Anxiety/Depression before implantation. Three months after LAAC, both groups showed a significant improvement in mobility, self-care and usual activities. The female gender had a significant improvement in health state 3 months after implantation than their male counterparts. Conclusion: Our data shows an improvement in mobility, self-care, usual activities and the overall health state in all patients after LAAC. This potential improvement, most likely caused by the discontinuation of oral anticoagulants, should be considered an indication for LAAC.

Acute upper limb ischemia is considered a vascular emergency. These events are mostly thromboembolic and are often detected in patients with atrial fibrillation (AF). Surgical thrombectomy and percutaneous mechanical thrombectomy are the usual methods to treat this medical emergency. In this case, we report the case of a 75-years old woman with a history of AF who initially presented to our center because of syncope resulting from Torsades de pointes due to a known long-QT syndrome. Those episodes were treated adequately from the implanted ICD. In addition to the symptoms of syncope, the patient also noted symptoms of right upper-limb ischemia. Using duplex sonography, we noticed a thrombotic occlusion at the level of the axillary artery. Using femoral access, we performed an antegrade angiography of the axillary artery, which confirmed a fresh thrombotic occlusion. The initially performed thrombus aspiration wasn't successful, and the decision was made to use an ekosonic endovascular system (Ekosonic ™ Endovascular System, Boston Scientific, EKOS) catheter to perform catheter-directed thrombolysis. Locally, 10 mg Actilyse were administrated. Then an EKOS Catheter was delivered to the occlusion area and was placed for 6 h. Symptoms of ischemia were resolved, and the angiographic control showed normal flow in the axillary artery. The patient was discharged without any local deficits of the right hand.

Background and purpose: Left atrial (LA) cardiac disease is a suspected cause of embolic stroke of undetermined source (ESUS). We tested the hypothesis that LA fibrosis, quantified using late-gadolinium-enhancement magnetic resonance imaging (LGE-MRI), predicts recurrent stroke or atrial fibrillation (AF) in patients with ESUS. Methods: We compared atrial fibrosis in healthy controls and patients with lacunar stroke, ESUS, and known AF with or without prior stroke. We followed patients with ESUS prospectively for the primary outcome of recurrent ischemic stroke, incident AF, or both. Results: We enrolled 203 patients from three centers: 103 patients without AF (35 healthy controls, 15 with lacunar strokes, 53 with ESUS) and 100 patients with AF (50 with and 50 without prior stroke). Patients with ESUS had significantly higher atrial fibrosis (15.0 ± 6.2%) compared to healthy controls (8.1 ± 7.9%

Objectives This subanalysis of the CASTLE-AF (Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF) trial aimed to address the association between atrial fibrillation (AF) recurrence, AF burden, and hard clinical outcomes in heart failure (HF) patients with AF. Background The CASTLE-AF trial demonstrated the benefit of CA compared to pharmacological treatment in decreasing mortality and CV hospitalizations in patients with AF and HFrEF. However, the impact of AF recurrence and AF burden after ablation on long-term treatment benefit remains unknown. Methods The CASTLE-AF protocol randomized 363 patients with coexisting HF and AF in a multicenter prospective controlled fashion to catheter ablation (n = 179) versus pharmacological therapy (n = 184). Two hundred eighty patients were included in this subanalysis (as-treated), 128 of them underwent ablation and 152 received pharmacological treatment. All patients had implanted dual chamber or biventricular implantable defibrillators with activated home monitoring capabilities. The individual AF burden was calculated as the percentage of the atrial arrhythmia time per day. Results AF burden at baseline was not predictive of the primary endpoint (p = 0.473) or all-cause mortality (p = 0.446). AF recurrence (defined as any episode >30 s) did not show any relationship with the primary endpoints of mortality and occurrence of HF, irrespective of the treatment arm. An AF burden below 50% after 6 months of catheter ablation, was associated with a significant decrease in primary composite outcome (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.15 to 0.71; p = 0.014) and all-cause mortality (HR: 0.23; 95% CI: 0.07 to 0.71; p = 0.031). The risk of the primary endpoint or mortality was directly related to a low ( Conclusions AF burden at 6 months was predictive of hard clinical outcomes in HF patients with AF. The first recurrent atrial tachyarrhythmia episode >30 s after ablation was not associated with improvement in mortality and hospitalization for HF. (Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF [CASTLE-AF]; NCT00643188 )

Introduction Success rates of catheter ablation in persistent atrial fibrillation (AF) remain suboptimal. A better and more targeted ablation strategy is urgently needed to optimize outcomes of AF treatment. We sought to assess the safety and efficacy of targeting atrial fibrosis during ablation of persistent AF patients in improving procedural outcomes. Methods The DECAAF II trial (ClinicalTrials. gov identifier number NCT02529319) is a prospective, randomized, multicenter trial of patients with persistent AF. Patients with persistent AF undergoing a first-time ablation procedure were randomized in a 1:1 fashion to receive conventional pulmonary vein isolation (PVI) ablation (Group 1) or PVI + fibrosis-guided ablation (Group 2). Left atrial fibrosis and ablation induced scarring were defined by late gadolinium enhancement magnetic resonance imaging at baseline and at 3-12 months postablation, respectively. The primary endpoint is the recurrence of atrial arrhythmia postablation, including atrial fibrillation, atrial flutter, or atrial tachycardia after the 90-day postablation blanking period. Patients were followed for a period of 12-18 months with a smartphone ECG Device (ECG Check Device, Cardiac Designs Inc.). With an anticipated enrollment of 900 patients, this study has an 80% power to detect a 26% reduction in the hazard ratio of the primary endpoint. Results and conclusion The DECAAF II trial is the first prospective, randomized, multicenter trial of patients with persistent AF using imaging defined atrial fibrosis as a treatment target. The trial will help define an optimal approach to catheter ablation of persistent AF, further our understanding of influencers of ablation lesion formation, and refine selection criteria for ablation based on atrial myopathy burden.

Cardiac magnetic resonance (cMR), a well-established imaging tool, is indispensable in the diagnosis and management of cardiovascular disease. Given its high spatial resolution and ability to characterize tissue, cMR represents the gold standard in determining myocardial viability. Gadolinium-based contrast-enhanced cMR can accurately identify myocardial scars and fibrosis in the ventricle and the atria, and differentiate it from normal myocardium. Gadolinium is an extracellular molecule which has been shown to be safe and beneficial in magnetic resonance imaging (MRI). Due to the larger extracellular space in myocardial scars, there is more uptake (wash-in) and slower elimination (wash-out) of gadolinium in those areas as opposed to normal myocardium. When imaged several minutes after intravenous administration of gadolinium, nonviable myocardial areas appear brighter than viable myocardium. The use of late-gadolinium enhancement (LGE) technique in assessing myocardial viability has been shown to highly correlate with histological examinations. Furthermore, this technique is highly reproducible and has very high intra- and interobserver agreement. Extent of LGE after myocardial infarction predicts the occurrence of adverse cardiovascular events. Moreover, LGE is highly accurate in predicting functional recovery of dysfunctional myocardial segments in patients undergoing revascularization and consequently has a key role in guiding revascularization procedures. In addition, use of LGE in the identification of myocardial fibrosis or myocardial damage in inflammatory myocardial disease helps to differentiate the type of cardiomyopathy and to predict sudden cardiac death among patients with heart failure. The role of LGE-MRI in the field of electrophysiology through recognition of different substrate for arrythmias and guiding the ablation therapy is steadily increasing and has fundamentally changed our understanding of atrial myopathy.Die kardiale Magnetresonanztomographie (Kardio-MRT) ist ein etabliertes Verfahren in der Bildgebung des Herzens und stellt eine unverzichtbare Methode in der Diagnose und Behandlung von kardiovaskulären Erkrankungen dar. In Anbetracht ihrer Fähigkeit zur Gewebecharakterisierung stellt die Kardio-MRT den Goldstandard bei der Evaluation der myokardialen Vitalität dar. Die gadoliniumbasierte kontrastverstärkte Kardio-MRT ermöglicht eine genaue Detektion von Myokardnarben und myokardialer Fibrose sowie eine Differenzierung zwischen vitalem und avitalem Myokard im Ventrikel und in den Vorhöfen. Gadolinium ist ein extrazelluläres Molekül, welches in der MRT angewendet wird. Im Gegensatz zu normalem Myokard befindet sich in den Narbenarealen ein größerer Extrazellulärraum, was zu einer stärkeren Aufnahme (Wash-in) und zu einem verzögerten Wash-out des Kontrastmittels führt. Durch höhere verbleibende Konzentration des Kontrastmittels kommt es in diesem Bereich zu einer stärkeren Signalanhebung, daher erscheinen die Narbenareale heller als das normale Myokard. Eine Übereinstimmung der durch das LGE bestimmten Myokardnarben mit der histologisch detektierten myokardialen Nekrose konnte nachgewiesen werden. Das Ausmaß des LGE bietet prognostische Informationen und korreliert mit unerwünschten kardiovaskulären Ereignissen bei Patienten nach akutem Myokardinfarkt. Bei Patienten mit ischämischer Kardiomyopathie und chronisch verschlossenen Gefäßen konnte mittels LGE eine Wiederherstellbarkeit einer regelrechten Kontraktilität der dysfunktionalen myokardialen Abschnitte nach Revaskularisierung vorhergesagt werden. Die Anwendung des LGE zur Erkennung myokardialer Fibrose ermöglicht die Differenzierung verschiedener Kardiomyopathien sowie eine Abschätzung des Risikos eines plötzlichen Herztods bei Patienten mit eingeschränkter Pumpfunktion. Die Rolle des LGE im Bereich der Elektrophysiologie bei der Erkennung der Substrate verschiedener Herzrhythmusstörungen nimmt stetig zu und hat unser Verständnis der atrialen Myopathie grundlegend verändert.

High-risk coronary intervention involving the left main coronary artery represents an indication for mechanical circulatory support in hemodynamically unstable patients. Extracorporeal membrane oxygenation permits adequate hemodynamic stabilization and myocardial recovery from life-threatening pulmonary and cardiac failure. Our case report demonstrates the importance of choosing the correct method of hemodynamic support in different case scenarios. (Level of Difficulty: Advanced.), Graphical abstract

Aim: The use of shockwave lithotripsy for the treatment of heavily calcified atherosclerotic plaques before stenting showed great results in terms of feasibility and safety with favorable initial success. Evidence suggests that it is a useful tool to treat calcified lesions in peripheral and coronary arteries. Here, we describe the case of a patient with calcified renal artery stenosis successfully treated with the shockwave lithotripsy system. Case Report: We present a 76-year-old man with a known significant atherosclerotic renal artery stenosis and refractory hypertension. The patient received an angioplasty of the right renal artery in the first session and he was admitted for a second session to intervene in the left renal artery. The lesion was successfully treated with the lithotripsy system. Final angiography demonstrated an excellent position of the stent and good wall apposition. Conclusion: Our clinical case demonstrates that lithotripsy is safe and effective also for the treatment of the renal artery.

ZUSAMMENFASSUNGDer interventionelle perkutane Vorhofohrverschluss (LAAC) bietet eine Alternative für Ärzte, die einer komplizierten Nutzen-Risiko-Analyse bei Patienten mit Vorhofflimmern (VHF) gegenüberstehen, die aufgrund ihres Schlaganfallrisikos eine orale Antikoagulation (OAK) erhalten sollten, aber auch ein hohes Blutungsrisiko haben. Eine Steigerung dieses Bewusstseins in verschiedenen medizinischen Disziplinen hinweg könnte eine alternative Strategie zur Schlaganfallprävention für Patienten darstellen, die derzeit nicht ausreichend geschützt sind.

(1) Background: The modified anterior line (MAL) has been described as an alternative to the mitral isthmus line. Despite better ablation results, achieving a bidirectional line block can be challenging. We aimed to investigate the ablation parameters that determine a persistent scar on late-gadolinium enhancement magnet resonance imaging (LGE-MRI) as a surrogate parameter for successful ablation 3 months after MAL ablation. (2) Methods: Twenty-four consecutive patients who underwent a MAL ablation have been included. The indication for MAL was perimitral flutter (n = 5) or substrate ablation in the diffuse anterior left atrial (LA) low-voltage area in persistent atrial fibrillation (AF) (n = 19). The MAL was divided into three segments: segment 1 (S1) from mitral annulus to height of lower region of left atrial appendage (LAA) antrum; segment 2 (S2) height of lower region of LAA antrum to end of upper LAA antrum; segment 3 (S3) from end of upper LAA antrum to left superior pulmonary vein. Ablation was performed using a contact force irrigated catheter with a power of 40 Watt and guided by automated lesion tagging and the Ablation Index (AI). The AI target was left to the operator’s choice. An inter-lesion distance of ≤6 mm was recommended. The bidirectional block was systematically evaluated using stimulation maneuvers at the end of procedure. All patients underwent LGE-MRI imaging at 3 months, regardless of symptoms, to identify myocardial lesions (scars). (3) Results: Bidirectional MAL block was achieved in all patients. LGE-MRI imaging revealed scarring in 45 of 72 (63%) segments. In all three segments of MAL, ablation time and AI were significantly higher in scarred areas compared with non-scar areas. The mean AI value to detect a durable scar was 514.2 in S1, 486.7 in S2 and 485.9 in S3. The mean ablation time to detect a scar was 20.4 s in S1, 22.1 s in S2 and 20.2 s in S3. Mean contact force and impedance drop were not significantly different between scar and non-scar areas. (4) Conclusions: Targeting optimal AI values is crucial to determine persistent left atrial scars on an LGE-MRI scan 3 months after ablation. AI guided linear left atrial ablation seems to be effective in producing durable lesions.

Introduction: Symptomatic mitral regurgitation (MR) is associated with a high mortality rate and high HF-related hospitalization. Symptomatic therapy in the elderly and very elderly patients remains weak in controlling severe MR. Patients with an increased risk of surgical repair of the MR seemed to benefit from MitraClip procedures. Hypothesis: Therefore, we thought to analyze the postprocedural safety and success of the MitraClip in octogenarians and older patients. Methods: Elderly patients with severe and symptomatic MR were presented and evaluated in the heart team. Patients with high surgical risks underwent MitraClip (Abbot, USA) procedure in our center. Post-procedural transthoracic echocardiography (TTE) procedure was performed to determine the MR grade and exclude procedure-related complications. Results: Two hundred eleven consecutive patients, older than 80 years (83.75 ±2.95, 106 Men (83.5±3.06) and 105 Women (84.01±2.83)), who received MitraClip between May 2015 and May 2020 were enrolled. The baseline characteristics are presented in table 1. Procedural success, defined as reducing the MR to grad I-II, was achieved in 93% of the patients (3.11±0.34 vs. 1.25±0.46, P = 0.002). All patients improved in the New York Heart Association functional class (3.04±0.40 vs. 1.92±0.76 one year after the intervention). No procedure-related death was registered. 81% (n=168) survival rate was achieved one year after the intervention. No clip embolization was detected in 3 months echocardiography control, Table 2. Conclusions: Our preliminary results indicate that MitraClip is a safe and effective therapeutic option in Elderly and very elderly patients with severe MR and high surgical risks. Therefore, this therapy should be considered despite age and comorbidities for effective symptomatic treatment in this particular cohort.

Background and case summary We report a case of a 76-year-old female who was admitted to our hospital because of dyspnoea caused by a known high-grade tricuspid valve regurgitation (TR). The patient received an edge-to-edge reparation of the tricuspid valve 1 month before the current admission using the TriClip XTR (Clip) system. The post-interventional echocardiographic results were satisfying, and the patient was discharged with TR grade I. At this new admission, the echocardiographic control showed a missing Clip on the tricuspid valve with a recurrent high-grade regurgitation. Fluoroscopy showed the dislocated Clip at the level of the femoral vein. This was also confirmed using Duplex sonography with no signs of thrombosis or embolization. The challenge was how to extract the Clip using endovascular methods as the patient refused any kind of surgical removal. We managed to remove the 20 × 10 mm big clip using transfemoral access and an endovascular snare system. No post-interventional complications were registered. The patient was discharged after the intervention with a new scheduled Clip procedure. Discussion This case shows a possible safe and challenging alternative to removing dislocated Clip from the femoral vein. Experienced operators are required to have the knowledge and skills to manage these possible procedural complications using the appropriate apparatus. A surgical technique would be, in this case, common practice, however as the patient declined surgical intervention, the endovascular approach was the alternative option.

The advances in the left atrial appendage closure as a stroke prevention method in patients with atrial fibrillation and contraindications to oral anticoagulants made a huge revolution offering a great alternative for patients with a high risk of bleeding. The nitinol-based, self-expanding LAmbre closure system shows promising initial results in terms of efficacy and safety in worldwide different clinical trials offering an alternative to the known Amulet and Watchman closure systems. Lifetech received CE Mark approval for the LAmbre closure system on 15 June 2016. Different studies have shown encouraging results in terms of feasibility and efficacy of the novel occluder. The favorable device design gives a big advantage in the occlusion of difficult left atrial appendage anatomy.

ZUSAMMENFASSUNGKardiale Embolien sind nach wie vor eine weltweit führende Ätiologie ischämischer Schlaganfälle. Obwohl sich die Pathologien, die zu den Embolien führen, in den letzten 10 Jahren nicht geändert haben, wurden bedeutende Fortschritte bei den Behandlungs- und Schlaganfallverhütungsmethoden für diese Krankheitsbilder erzielt. Vorhofflimmern (VHF) gilt mit einem Anteil von 20–30 % als die häufigste Ursache kardioembolischer Schlaganfälle. Goldstand zur Schlaganfallprophylaxe bei VHF bleibt nach wie vor die orale Antikoagulation (OAK). Hier hat sich in den letzten Jahren bei geeigneten Patienten eine Überlegenheit der nicht-Vitamin-K-abhängigen oralen Antikoagulanzien (NOAK) gegenüber den Vitamin-K-Antagonisten (VKA) gezeigt. Fortschritte beim Verschluss des linken Herzohrs als Schlaganfallprävention bei VHF-Patienten mit Kontraindikationen für eine OAK haben das Feld revolutioniert und eine Möglichkeit für Patienten mit höherem Blutungsrisiko geschaffen. Aktuelle Studien zeigen, dass diese Maßnahme, verglichen mit den VKA, einen ähnlichen Schutz vor Schlaganfall bietet – bei weniger Blutungskomplikationen im Langzeitverlauf. Darüber hinaus konnte die initial relativ hohe periprozedurale Komplikationsrate in den letzten Jahren deutlich gesenkt werden. Ein direkter Vergleich zwischen NOAK und dem interventionellen Vorhofohrverschluss steht noch aus. Daher wird von den Leitlinien empfohlen, den Verschluss des linken Vorhofohrs nur bei Patienten mit eindeutiger Kontraindikation gegen eine OAK in Erwägung zu ziehen (Empfehlungsgrad IIb, Evidenzgrad B).Die Rolle des Foramen-ovale-Verschlusses für die Sekundärprävention bei ausgewählten Patienten mit kryptogenem ischämischem Schlaganfall in einem relativ jungen Alter ist dank der jüngsten Veröffentlichung der Langzeitergebnisse aus 3 großen Studien klarer geworden. Daher wird von den neuen Leitlinien empfohlen, dass bei Patienten zwischen 16 und 60 Jahren mit einem (nach neurologischer und kardiologischer Abklärung) kryptogenen ischämischen Schlaganfall und offenem Foramen ovale mit moderatem oder ausgeprägten Rechts-links-Shunt ein interventioneller PFO-Verschluss durchgeführt werden soll (Empfehlungsgrad I Evidenzgrad A).

BACKGROUND Unexpected high levels of atrial fibrosis are found in individuals with no history of atrial fibrillation (AF). The temporal behavior of atrial fibrosis in this population is still unknown. We sought to investigate the progression and predictors of atrial fibrosis in non-AF individuals. METHODS Non-AF individuals at baseline who underwent late gadolinium enhancement magnetic resonance imaging (LGE-MRI) for assessment of left atrial (LA) fibrosis at least twice were retrospectively included in this study. The incidence of AF was assessed using review of medical records. RESULTS In 42 non-AF patients (15 females, 65.9 ± 8.6 years old), all patients had a detectable level of LA fibrosis at baseline, ranging from 4.5% to 28.8%, with a mean of 12.9 ± 5.9%. LA fibrosis in the second LGE-MRI was significantly higher in all patients compared to the first measurement (mean value of 12.9 ± 5.9% vs. 17.34 ± 6.8%; p

Introduction: Late-gadolinium enhanced (LGE)-MRI has revealed atrial fibrotic remodeling in embolic stroke of undetermined source (ESUS) patients. Curiously, fibrosis levels in ESUS patients are the same as those observed in AF. A potential explanation is that ESUS patients have pre-clinical arrhythmic substrate, but lack the triggers needed to initiate AF. Hypothesis: Simulations in computational models reconstructed from LGE-MRI scans can determine if the fibrotic substrate of a particular ESUS patient has the capacity to sustain reentry. Methods: ESUS (per standard criteria) was verified by a neurologist. 45 ablation-naïve AF patients and 45 ESUS patients within three months of stroke underwent LGE-MRI for fibrosis assessment. Left atrial (LA) models were built from LGE-MRI scans. Fiber orientations were mapped into each LA model using universal atrial coordinates. Burst pacing from 15 sites was used to test inducibility of arrhythmia sustained by reentry (Fig A). Results: In 23/45 (51%) ESUS and 29/45 (64%) AF models, we observed sustained reentry. Fibrosis burden was significantly higher for patients in whom simulations suggested the existence of pre-clinical arrhythmic substrate; however, within the inducible and non-inducible sub-groups, there was no significant difference in fibrosis burden for ESUS vs. AF patients (Fig B). This suggests that the presence of pre-clinical substrate in ESUS is correlated with fibrosis burden, although exceptions to this supposition were not uncommon (i.e., inducible low-fibrosis and non-inducible high-fibrosis models; Fig C). Conclusions: In this modeling study, pro-arrhythmic properties of fibrosis in ESUS and AF are indistinguishable. This suggests that some ESUS patients have pre-clinical fibrotic substrate, but do not have AF due to a lack of suitable triggers. Ongoing clinical follow-up will test whether abundance of pre-clinical substrate is predictive of incident AF.

Introduction: About 5% of all COVID-19 patients require intensive care, mostly because of respiratory failure. Little is known about concomitant multi-organ manifestation under these circumstances. Methods: Retrospective observational study using routine data sets of 13 COVID-19 patients requiring mechanical ventilation in the Regiomed Hospital Coburg, Germany, between March 1 st and June 15 th , 2020. Results: Of 13 patients eligible for this study, all were intubated and ventilated mechanically, with signs of infiltration in chest radiographs. 4 suffered from renal failure and needed dialysis; 3 of these patients died, but none without renal failure. Proteinuria was found in all and microhematuria in all but one patients tested (n=11). All developed metabolic alkalosis (BEmax 9.75±0.99, mean ±SEM), and 6 afterwards polyuria (6.75 ±2.45l per day); both conditions resolved in all surviving patients but 1 spontaneously and were not related to prior renal failure. Liver enzymes were elevated in all patients (γGT 506 ±78U/l), but bilirubin levels only in 4; 2 of these died shortly after. Bacterial superinfection was found in 8 patients, and in all 3 ones finally dying. Rhabdomyolysis affected 12 patients (CKmax 1604±542U/l) and resolved later. All patients had slightly elevated troponin T (0.059 ±0.013ng/ml), and 7 had elevated nt-pro-BNP levels (3566±2359pg/ml), indicating cardiac COVID-19, and elevated d-dimer levels (18.1 ±6.68mg/dl) representing disseminated intravascular coagulation. No thromboembolic was observed. The need of catecholamines was low ( Conclusions: Our data indicate that severe COVID-19 is a multi-organ disease, even though ARDS is the leading problem; renal involvement - together with bacterial superinfection - seems to be a major risk factor for unfavorable disease development. Especially metabolic alkalosis and polyuria without overt renal failure have not been studied yet and require close clinical attention.

Cardiac magnetic resonance imaging (MRI) has revealed fibrosis in embolic stroke of undetermined source (ESUS) patients comparable to levels seen in atrial fibrillation (AFib). We used computational modeling to understand the absence of arrhythmia in ESUS despite the presence of putatively pro-arrhythmic fibrosis. MRI-based atrial models were reconstructed for 45 ESUS and 45 AFib patients. The fibrotic substrate’s arrhythmogenic capacity in each patient was assessed computationally. Reentrant drivers were induced in 24/45 (53%) ESUS and 22/45 (49%) AFib models. Inducible models had more fibrosis (16.7 ± 5.45%) than non-inducible models (11.07 ± 3.61%; p, eLife digest The heart usually beats with a regular rhythm to pump the blood that carries oxygen and nutrients to different organs. Sometimes, alterations in the heart’s rhythm known as arrhythmias can occur. Atrial fibrillation, also called AFib, is a type of arrhythmia in which the heart beats rapidly and irregularly, causing abnormal blood-flow that can lead to the formation of blood clots. If one of these blood clots travels to the brain, it can block a blood vessel, causing a stroke. However, many strokes occur without any evidence of AFib. One subset of strokes that are not associated with AFib are embolic strokes of undetermined source (ESUS), which account for 25% of all strokes. By definition ESUS and AFib do not occur together, but both are associated with similar elevated levels of disease-related remodeling (i.e., fibrosis) in the heart tissue, which appears when the heart is injured. Fibrosis impairs the heart’s normal electrical activity. Bifulco et al. wanted to determine whether there is some fundamental difference in fibrosis between people with AFib and those who have had an ESUS event. To do this, they used a computational approach to model the geometries and patterns of fibrosis of the hearts of 45 ESUS patients and 45 patients with AFib, essentially producing a virtual version of each patient’s heart. Bifulco et al. then applied a virtual pace-maker (working in overdrive mode) to each heart model to determine whether electrical inputs that can lead to AFib had different effects on ESUS and AFib patients. The results showed that the electrical inputs had similar effects in all of the heart models. This led Bifulco et al. to conclude that ESUS and AFib patients have indistinguishable patterns of fibrosis. The key difference is that ESUS patients are missing the trigger to initiate the fibrillation process – if atrial fibrosis is the proverbial tinderbox, these triggers are the spark needed to ignite a fire. Further research, including confirmation of Bifulco et al.’s findings in live patients, will be needed to confirm the hypothesis that ESUS patients lack AFib primarily due to an absence of triggers. If this is indeed the case, these findings may make it easier to identify ESUS patients at higher risk for AFib or further strokes. Additionally, a better understanding of fibrosis as a link between stroke and AFib will help clinicians provide better, more personalized treatments, for example guiding whether a patient should take blood thinners or undergo more rigorous cardiac monitoring.

Background: Recent data demonstrate promising effects on left ventricular dysfunction and left ventricular ejection fraction (LVEF) improvement following ablation for atrial fibrillation (AF) in patients with heart failure. We sought to study the relationship between LVEF, New York Heart Association class on presentation, and the end points of mortality and heart failure admissions in the CASTLE-AF study (Catheter Ablation for Atrial Fibrillation With Heart Failure) population. Furthermore, predictors for LVEF improvement were examined. Methods: The CASTLE-AF patients with coexisting heart failure and AF (n=363) were randomized in a multicenter prospective controlled fashion to ablation (n=179) versus pharmacological therapy (n=184). Left ventricular function and New York Heart Association class were assessed at baseline (after randomization) and at each follow-up visit. Results: In the ablation arm, a significantly higher number of patients experienced an improvement in their LVEF to >35% at the end of the study (odds ratio, 2.17; P P =0.006), all-cause mortality (HR, 0.54; P =0.019), and cardiovascular hospitalizations (HR, 0.66; P =0.017). In the ablation group, New York Heart Association I/II patients at the time of treatment had the strongest improvement in clinical outcomes (primary end point: HR, 0.43; P P =0.001). Conclusions: Compared with pharmacological treatment, AF ablation was associated with a significant improvement in LVEF, independent from the severity of left ventricular dysfunction. AF ablation should be performed at early stages of the patient’s heart failure symptoms.

This subanalysis of the CASTLE-AF (Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF) trial aimed to address the association between atrial fibrillation (AF) recurrence, AF burden, and hard clinical outcomes in heart failure (HF) patients with AF.The CASTLE-AF trial demonstrated the benefit of CA compared to pharmacological treatment in decreasing mortality and CV hospitalizations in patients with AF and HFrEF. However, the impact of AF recurrence and AF burden after ablation on long-term treatment benefit remains unknown.The CASTLE-AF protocol randomized 363 patients with coexisting HF and AF in a multicenter prospective controlled fashion to catheter ablation (n = 179) versus pharmacological therapy (n = 184). Two hundred eighty patients were included in this subanalysis (as-treated), 128 of them underwent ablation and 152 received pharmacological treatment. All patients had implanted dual chamber or biventricular implantable defibrillators with activated home monitoring capabilities. The individual AF burden was calculated as the percentage of the atrial arrhythmia time per day.AF burden at baseline was not predictive of the primary endpoint (p = 0.473) or all-cause mortality (p = 0.446). AF recurrence (defined as any episode30 s) did not show any relationship with the primary endpoints of mortality and occurrence of HF, irrespective of the treatment arm. An AF burden below 50% after 6 months of catheter ablation, was associated with a significant decrease in primary composite outcome (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.15 to 0.71; p = 0.014) and all-cause mortality (HR: 0.23; 95% CI: 0.07 to 0.71; p = 0.031). The risk of the primary endpoint or mortality was directly related to a low (50%) or high (≥50%) AF burden at 6 months post-ablation.AF burden at 6 months was predictive of hard clinical outcomes in HF patients with AF. The first recurrent atrial tachyarrhythmia episode30 s after ablation was not associated with improvement in mortality and hospitalization for HF. (Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF [CASTLE-AF]; NCT00643188).

The value of antiarrhythmics to maintain normal sinus rhythm in patients with atrial fibrillation (AF) and heart failure (HF) is still being debated. We aimed to determine whether rhythm control using antiarrhythmic drugs (AADs) is more effective than rate control in improving outcomes in this population. In this sub-analysis of the CASTLE-AF study, we included patients that were treated pharmacologically either to maintain sinus rhythm or to achieve rate control. The primary endpoint was defined as a composite of death from any cause or worsening of HF that led to an unplanned overnight hospitalization. Among 210 patients (mean age of 64.1 ± 10.8 years, 83.3% male) treated pharmacologically, 60 patients were in the rhythm control group and 150 were in the rate control group. Patients in the rhythm control group were less likely to be assigned a beta-blocker (53 (88.3%) vs 141 (97.9%), P = 0.004) and digitalis (8 (13.3%) vs 53 (36.8%), P

BackgroundMost respiratory viruses show pronounced seasonality, but for SARS-CoV-2 this still needs to be documented.MethodsWe examined the disease progression of COVID-19 in 6,914 patients admitted to hospitals in Europe and China. In addition, we evaluated progress of disease symptoms in 37,187 individuals reporting symptoms into the COVID Symptom Study application.FindingsMeta-analysis of the mortality risk in seven European hospitals estimated odds ratios per one day increase in the admission date to be 0.981 (0.973-0.988, pInterpretationSeverity of COVID-19 in Europe decreased significantly between March and May and the seasonality of COVID-19 is the most likely explanation.

Background The modified anterior line (MAL) has been described as an alternative to the mitral isthmus line. Despite better ablation results, achieving a bidirectional line block is sometimes challenging. Ablation Index (AI) is a novel lesion quality marker that integrates contact force, time and power. This index has been evaluated for pulmonary vein isolation (PVI) but not for other left atrial (LA) lesions. We aimed to investigate the AI-values to determine a scar on cardiac magnetic resonance (CMR) imaging 3 months after MAL ablation. Methods Twelve consecutive patients who underwent a MAL ablation have been included. The indication for MAL was perimitral flutter (n = 3) or substrate ablation for diffuse anterior LA low-voltage area in persistent atrial fibrillation (AF) (n = 9). The MAL was divided into three segments: segment 1 (S1) from mitral annulus to height of lower begin of left atrial appendage (LAA) antrum; segment 2 (S2) height of lower begin of LAA antrum to end of upper LAA antrum; segment 3 (S3) from end of upper LAA antrum to left superior pulmonary vein. Ablation was performed using a contact force catheter, automated lesion tagging and Ablation Index. AI target was left to the operator’s choice. An inter-lesion distance of ≤ 6mm was recommended. The bidirectional block was systematically evaluated at the end of procedure. All patients underwent a CMR study at 3 months, regardless of symptoms, to identify myocardial lesions (scar). Results Bidirectional MAL block was achieved in all patients. The mean reached AI value was 443 ± 55. CMR imaging revealed scar in 25 of 36 (69%) segments. In total, the mean AI value for detecting a scar was 451 ± 51 and was higher in S1 compared to S2 and S3 (474 ± 36 vs. 451 ± 63 vs. 423 ± 46, respectively). The AI value in S1 was significantly higher compared to S3 (p = 0.02). The minimal AI value to detect a scar was 410 ± 183 in S1, 379 ± 109 in S2 and 369 ± 68 in S3. Conclusion Different AI targets are required for each segment of the MAL to show transmural lesions on CMR imaging 3 months post-ablation. Higher AI values are required for the lower segment of the line. Additional data are needed to demonstrate if considering these targets will be reflected in better long-term results.

Background Atrial fibrillation (AF) is a complex arrhythmia and several mechanisms that might coexist have been proposed. Recent technical advances opened the way to better mapping possibilities and might contribute to target more specific components of the AF substrate. Objective The aim of this study was to evaluate a spatial correlation between AF drivers as determined by a novel non-contact unipolar high-resolution system and atrial fibrosis assessed by cardiac magnetic resonance imaging (MRI). Methods Patients undergoing a first ablation procedure for persistent AF were included. Prior to ablation, a Late Gadolinium-Enhancement (LGE) MRI was performed to detect the fibrotic atrial tissue. The procedure was performed using a new non-contact unipolar high-resolution system allowing a 3D anatomy reconstruction with a continuous dipole density mapping. Three different wave front patterns were analyzed in the left atrium (LA): 1) focal activity (FA), 2) localized rotational activation (LRA) and 3) localized irregular activation (LIA). The spatial distribution of these AF drivers was analyzed prior to AF ablation. Results A total of 49 patterns in 6 patients were identified, among them 22 FA, 14 LRA and 13 LIA. The posterior (n = 14), anterior wall (n = 13) and roof (n = 8) were identified as predominant driver sites. 31/49 (59%) drivers had a strong correlation with late enhancement in MRI. Most of the LIA, LRA and FA were embedded infibrotic areas (LIA 10/13 (77%); LRA 9/14 (64%) and FA 12/22 (54%). The postero-inferior LA showed the best correlation between drivers and fibrosis, the antero-septal LA the weakest one. Conclusion There is a significant overlap between AF driver regions identified by dipole density mapping and atrial fibrosis assessed by MRI. Most of AF drivers are embedded in fibrotic areas, particularly in case of localized irregular activity and at the posterior LA. Abstract Figure.

Background Optimal antithrombotic therapy following left atrial appendage closure (LAAC) with the Watchman occluder remains uncertain. This study retrospectively compared clinical outcomes of a 3-month dual antiplatelet therapy (DAPT group) and a protocol of anticoagulation plus aspirin for 45 days followed by DAPT for 6 months (ACT group) after LAAC with the Watchman device. Methods Of two Watchman registries (Coburg and Lichtenfels hospitals, Germany), 220 and 304 consecutive patients with successful LAAC were included. Patients in Coburg hospital received DAPT while they received ACT in Lichtenfels. After a 1:1 propensity score matching, 174 (DAPT) versus 174 (ACT) patients were compared by use of the primary efficacy endpoint of thromboembolic events and cardiovascular/unexplained death, the primary safety endpoint of nonprocedural related major bleeding events at follow-up, and the combined hazard endpoint, a composite of all above-mentioned hazards. Results The mean age 77.5 ± 7.2 (DAPT) versus 77.3 ± 7.1 (ACT) years, CHA2 DS2 -VASc score 4.6 ± 1.5 versus 4.7 ± 1.6, and HAS-BLED score 3.3 ± 0.8 versus 3.3 ± 0.8 were similar. After 12 months, the clinical efficacy (13/174, 7.4% [DAPT] vs 11/174, 6.3% [ACT]; hazard ratio [HR], 0.84; 95% confidence interval [CI], 0.38-1.86; P = .66) and safety (6/174, 3.4% vs 8/174, 4.5%; HR, 0.86; 95% CI, 0.29-2.56; P = .79) as well as the combined hazard endpoint (18/174, 10.3% vs 18/174, 10.3%; HR,1.01; 95% CI, 0.53-1.95; P = .97) were comparable. Conclusions This study suggests comparable efficacy and safety of 3-month DAPT versus 6 weeks ACT plus aspirin following LAAC with the Watchman.

Aim Age and female sex are associated with a higher risk of stroke in atrial fibrillation (AF). We sought to determine whether advancing age and female sex are associated with higher atrial fibrosis. Methods and results We conducted an observational cohort study of patients with AF enrolled in the University of Utah AF Database and a non-AF control group who underwent late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) for atrial fibrosis quantification. Participants with contra-indications for contrast MRI scanning were excluded. Nine hundred and eight consecutive men and women with AF and 15 non-AF controls were included in this study. Left atrial fibrosis increased with age in both men and women with AF. Women with AF (n = 316) were older than men (n = 592): mean age 68.7±11.6 vs. 64.9±11.7 years; P

Background Atrial fibrillation (AF) is the most frequent arrhythmia with a prevalence of 1%–2% in the general population. Oral anticoagulation (OAC) is state-of-the art for preventions of thromboembolic events, in particular ischemic stroke, in patients with atrial fibrillation. Despite its proven benefit, numerous studies have documented under use of OAC for a variety of reasons. Purpose To establish a program of nurse counseling in patient with atrial fibrillation and treatment with oral anticoagulation. The program is designed to improve patients satisfaction, compliance to OAC, prevention of medication errors, ischemic and bleeding events. Methods Patients with atrial fibrillation and treatment with oral anticoagulation were prospectively identified at the department of cardiology of our clinic. They received a 30 minutes nurse counseling about oral anticoagulation during the hospital stay and another 30 minutes telephone counseling 3 months after inclusion. Furthermore, they received a brochure to inform about atrial fibrillation, oral anticoagulation and methods to improve medication compliance. Demographic characteristics with stroke and bleeding risk (CHA2DS2-VASc and HAS-BLED scores), as well as procedural data were systematically assessed in a predefined standardized way and captured in a dedicated database. Results Between June 2017 and January 2018, a total of 617 patients (female gender: 43.1%) with atrial fibrillation and oral anticoagulation received nurse counseling. Demographic and follow-up data of 204 patients (female gender: 85/204 (41.7%); mean age 69.7±17.3, CHA2DS2-VASc score 4.2±1.7, HAS-BLED score 2.8±0.37) were assessed in a dedicated database. Indication for OAC was paroxysmal and persistent/permanent AF in 110/204 (53.9%), 93/204 (45.6%) and others 17 (8.3%), respectively. 33/2014 (16.2%) were treated with vitamin K antagonists, and 172/204 (84.3%) with non-vitamin K antagonists. After a follow-up of 0.46±2.9 years and 187 patients-years the rates of cardiovascular death, major bleeding events and all-cause stroke and TIA were 1.07%, 2.14% and 1.61% per 100 patient-years. Conclusion Nurse counseling in patients with atrial fibrillation and treatment with oral anticoagulation has been established at the REGIOMED clinics, Germany. Its effectiveness in terms of quality of live, medication complications and cardiovascular events has to be proven in a randomised trial. Acknowledgement/Funding Daichi-Sankyo

Catheter ablation is nowadays the core treatment of atrial fibrillation (AF). Propofol infusion sedation is an accepted safety strategy; however, respiratory depression with respiratory variations is frequent. Noninvasive mechanical ventilation (NIV) added to deep sedation could improve procedural safety and success. We sought to assess the predictive factors and safety of NIV in combination to propofol deep sedation in left atrial ablation procedures. Procedural data from 252 consecutive patients who underwent left atrial ablation (166 [66%] persistent, 86 [34%] for paroxysmal AF) were analyzed. Sedation with 1% propofol was used in all procedures and controlled by electrophysiologists. Arterial blood gas analysis was performed regularly during the procedure. NIV was indicated for respiratory depression with pH 50 mm Hg or agitated patient with the need for more profound sedation. No patient needed endotracheal intubation, and no procedure was abandoned due to adverse effects of sedation. NIV was used in 25 patients (10%). Predictive factors for the use of NIV were high-dose propofol sedation (p = 0.010), persistent AF (p = 0.029), prolonged procedure time (p = 0.006), increased body mass index (p = 0.008) and presence of obstructive sleep apnea (OSA; p

MRI Assessment of Ablation-Induced Scarring in Atrial FibrillationBackground There is limited knowledge on the extent and location of scarring that results from catheter ablation and its role in suppressing atrial fibrillation (AF). We examined the effect of atrial fibrosis and ablation-induced scarring on catheter ablation outcomes in AF. Methods We conducted a prospective multicenter study that enrolled 329 AF patients presenting for catheter ablation. Delayed enhancement magnetic resonance imaging (DE-MRI) of the left atrium was obtained preablation. Scarring was evaluated in 177 patients with a DE-MRI scan obtained 90 days postablation. We evaluated residual fibrosis, defined as preablation atrial fibrosis not covered by ablation scar. The primary outcome was freedom from recurrent atrial arrhythmia. Results In the analysis cohort of 177 patients, preablation fibrosis was 18.7 ± 8.7% of the atrial wall. Ablation aimed at pulmonary vein (PV) isolation was performed in 163 patients (92.1%). Ablation-induced scar averaged 10.6 ± 4.4% of the atrial wall. Scarring completely encircled all 4 PVs only in 12 patients (7.3%). Residual fibrosis was calculated at 15.8 ± 8.0%. At 325 days follow-up, 35% of patients experienced recurrent arrhythmia. Multivariable Cox proportional hazards models demonstrated that baseline atrial fibrosis (HR and 95% CIs) (1.09 [1.06–1.12], P < 0.001) and residual fibrosis (1.09 [1.05–1.13], P < 0.001) were associated with atrial arrhythmia recurrence, while PV encirclement and overall scar were not. Conclusions Catheter ablation of AF targeting PVs rarely achieves permanent encircling scar in the intended areas. Overall atrial fibrosis present at baseline and residual fibrosis uncovered by ablation scar are associated with recurrent arrhythmia.

Aims To compare ablation lesion formation after pulmonary vein isolation (PVI) using the standard cryoballoon (CB-S) vs. the re-designed cryoballoon Arctic Front Advance (CB-A) using late gadolinium enhancement magnetic resonance imaging (LGE-MRI) 3 months post-ablation. Methods and results Thirty-six consecutive patients with paroxysmal or short-lasting persistent atrial fibrillation (AF) were evaluated prospectively after PVI using the CB-S in the first 18 patients and the CB-A in the subsequent 18 patients. All patients underwent LGE-MRI and a 7-day Holter electrocardiogram monitoring 3 months after ablation. Fifty-six per cent of the patients were male (mean age 63.0 ± 9.1 years). Fifty-six per cent in the first group and 89% in the second group were free of AF recurrence 3 months after ablation ( P = 0.025). Three months after ablation, LGE-MRI of the left atrium showed complete circular lesions in 35% of PVs in the first group and in 32% of PVs in the second group (n.s.). The left PVs showed a significantly higher proportion of PV segments with complete ablation lesions compared with the right PVs (83 vs. 34%; P < 0.001). Conclusion Cardiac MRI is able to visualize induced ablation lesions after PVI and might be suitable to quantify ablation lesion amount. Ablation lesion formation did not differ significantly in patients treated with the CB-S vs. the CB-A, despite a significantly lower rate of AF recurrence after 3 months in the CB-A group. Left PVs showed a significantly higher amount of ablation lesions compared with the right PVs. Larger and randomized studies are needed to understand the relationship between representable tissue lesions and success rates.

Background: We report about a very interesting and none common finding observed using transthoracic echocardiography (TTE). A patient with new documented symptomatic atrial fibrillation (AF) who was admitted to our clinic for further clarification and stabilization received a routine TTE and transesophageal echocardiography (TEE) as a step before electrical cardioversion. The TTE revealed an extracardiac structure compressing the left atrium (LA), which was not observed on the TEE. For further clarification, the patient received a computer tomography of the chest which revealed an esophageal carcinoma. No specific symptoms of the disease were reported from the patient before this admission. Conclusion: TTE is the most commonly performed cardiac investigation. It provides generally very valuable information about cardiac structure and function. Our case shows the role of this method in identifying extra cardiac formation leading to important diagnosis.

AF Ablation and eGFR Introduction Chronic kidney disease (CKD) and atrial fibrillation (AF) often coexist. We studied the association of CKD with atrial fibrosis and the effect of AF ablation on kidney function. Methods AF patients who had a pre- and postablation serum creatinine and who completed a late gadolinium enhancement cardiac magnetic resonance imaging (MRI; LGE-MRI) prior to ablation were included. Estimated glomerular filtration rate (eGFR) was calculated and CKD was staged using the National Kidney Foundation guidelines. Patients with eGFR

Left atrial appendage closure (LAAC) is an established treatment strategy to reduce the risk of stroke in patients with non-valvular atrial fibrillation and contraindications for oral anticoagulation. Sex and gender specific differences are increasingly important for all cardiovascular diseases and