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Atrial fibrillation and heart failure are common cardiovascular conditions that are intricately linked to each other, with a significant impact on morbidity, mortality, and quality of life. These two conditions can create a vicious pathophysiologic milieu associated with neurohormonal changes, elevated cardiac filling pressure, myocardial remodeling, systemic and regional inflammation, fibrosis, and diminished myocardial contractility. It is well known that cardiomyopathy can cause atrial fibrillation and vice-versa, but often it is difficult to sort which came first. Unfortunately, the disease burden will only continue to rise with an aging population, and understanding the epidemiology of the disease and the interplay of these two conditions is vital to improved patient care., Competing Interests: Disclosures Dr N.V. Pothineni is a consultant to Boston Scientific. Dr R. Kabra is a consultant to Medtronic and Boston Scientific. Dr R. Gopinathannair is a consultant to Abbott and Boston Scientific. Dr D. Lakkireddy is a consultant to Abbott, Atricure, Alta Thera, Biotronik, Biosense Webster, Boston Scientific, and Medtronic., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Numerous states have introduced cardiopulmonary resuscitation (CPR) training mandates for high school students and staff to prevent sudden cardiac death (SCD). However, the content and implementation of these mandates vary substantially. Furthermore, a comprehensive and objective assessment of these mandates and their impact is lacking., Objective: We aimed to conduct a thorough evaluation of CPR training mandates across the United States., Methods: We developed a novel scoring system based on proposed CPR standards, training and certification requirements, and legislative action to assess current mandates. This was used to rate the CPR mandates across all 50 states and the District of Columbia. Mandate scores were then compared with available real-world registry data as a surrogate for efficacy from 2018 to 2021., Results: State CPR mandate scores ranged from 0 to 47, with a higher score indicating more robust mandates. The median and mean scores were 24 (interquartile range, 19.5-27) and 21.52 ± 8.61, respectively, with 35 being the highest score. Intraobserver variability was 0.986 (95% CI, 0.944-1.028; P < .001). The year of implementation did not influence the strength of the score (R 2 = -0.173; 95% CI, -0.447 to 0.131; P = .262). Correlation with SCD rate (R 2 = -0.76; 95% CI, -0.492 to 0.367; P = .742), bystander-initiated CPR (R 2 = -0.006; 95% CI, -0.437 to 0.427; P = .978), automated external defibrillator use (R 2 = -0.125; 95% CI, -0.528 to 0.324; P = .590), and cardiovascular death rate (R 2 = -0.13; 95% CI, -0.379 to 0.21; P = .355) failed to reach statistical significance., Conclusion: Modest scoring consistency highlights the need for robust, standardized CPR requirements to potentially mitigate SCD. This study lays the groundwork for evidence-informed policy development in this area., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Inadequate management of atrial fibrillation (AF) after stroke is associated with a worse prognosis, and the impact of early rhythm control with catheter ablation (CA) on neurological outcomes in these patients is poorly understood., Objectives: This study sought to evaluate the impact of early rhythm control with CA in patients with new-onset AF at the time of stroke., Methods: We performed a retrospective, observational study of patients hospitalized with stroke and new-onset AF from 2021 to 2023. Patients underwent routine care (n = 36) with rate control or antiarrhythmic drugs or rhythm control with CA (n = 36) after discharge. Functional neurological outcomes at admission, discharge, and 6 and 12 months were measured using the modified Rankin score-a scoring system from 0 to 6, describing patient activity levels. AF-related outcomes are also measured., Results: Though the modified Rankin score was similar at admission (4.5 ± 1.0 vs 4.4 ± 1.0; P = 0.717) and discharge (4.23 ± 0.7 vs 4.2 ± 0.8; P = 0.656), it was lower at 6 months (2.0 ± 0.7 vs 3.5 ± 0.8; P < 0.001) and 12 months (1.1 ± 0.8 vs 3.0 ± 1.0; P < 0.001) for those that underwent CA. They also had a faster time to rhythm control (54.5 ± 15.6 days vs 73.1 ± 26.3 days; P < 0.001) and continued AF freedom at 12 months (100% vs 13.9%; P < 0.001), with fewer repeat strokes (0% vs 13.9%; P = 0.091), major bleeding (11.1% vs 25%; P = 0.126), number of hospitalizations (0.4 ± 0.8 vs 1.8 ± 1.5; P < 0.001), and mortality (0% vs 11.1%; P < 0.001)., Conclusions: Early CA following the diagnosis of AF after a stroke is associated with significant improvement in neurologic outcomes, adverse events, and AF-related outcomes. Because of important differences in the study populations, it is uncertain whether these are directly attributable to early CA. Patients with stroke and AF may benefit from earlier CA, but additional studies are needed., Competing Interests: Funding Support and Author Disclosures Dr Garg is a consultant for Biosense Webster, Biotronik, Kestra, and Zoll. Dr DiBiase is a consultant to Abbott, Adagio, Atricure, Biosense Webster, Biotronik, Boston Scientific, and Medtronic. Dr Natale is a consultant to Abbott, Atricure, Biosense Webster, Biotronik, and Boston Scientific. Dr Lakkireddy is a consultant for Abbott, Atricure, Biosense Webster, Medtronic, and Johnson & Johnson. Dr Kabra is a consultant to Medtronic and Boston Scientific. Dr Pothineni is a consultant to Medtronic and Biosense Webster. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2025 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Implantable cardiac monitors (ICMs) provide valuable insights into managing atrial fibrillation (AF). Data suggest that ICMs increase AF detection, but their impact on management is still uncertain., Objective: We aimed to evaluate and to compare the impact of ICMs on the clinical management of AF., Methods: MONITOR-AF (NCT06352060) was a retrospective, multicenter study of patients with AF who received an ICM or routine monitoring with electrocardiograms or long-term monitoring between 2018 and 2021. Patients were observed for 12 months, with note made of AF-related clinical outcomes., Results: There were 2293 patients who received an ICM (n = 1115) or routine monitoring (n = 1178). Although comorbidities were significantly different between ICM and non-ICM groups, none of the AF-related characteristics were significantly different. Patients in the ICM group had more attempts at rhythm control with antiarrhythmic drugs (100% vs 59.9%; P < .001) and catheter ablation (91.7% vs 59.7%; P < .001). This led to higher freedom from AF at 12 months (86.0% vs 61.8%; P < .001) and freedom from antiarrhythmic drug (75.9% vs 39.4%; P < .001) and oral anticoagulation (69.6% vs 39.4%; P < .001) use and was associated with reduced rates of stroke (0.3% vs 1.6%; P < .001) and major bleeding (1.6% vs 2.9%; P < .001)., Conclusion: Dynamic monitoring with ICM is associated with beneficial AF outcomes with improved freedom from AF at 12 months and fewer complications. Thus, ICM use should be considered for the management of chronic AF., Competing Interests: Disclosures Dr Kabra is a consultant to Medtronic and Boston Scientific. Dr Pothineni is a consultant to Medtronic and Biosense Webster. Dr DiBiase is a consultant to Medtronic, Abbott, Biotronic, Biosense Webster, AtriCure, and Boston Scientific. Dr Natale is a consultant for Medtronic, Abbott, Biotronik, Biosense Webster, Atricure, and Boston Scientific. Dr Lakkireddy is a consultant for Abbott Vascular, Biotronic, Biosense Webster, Medtronic, Boston Scientific, AtriCure, Acutus, and Northeast Scientific., (Copyright © 2025 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

The complexity of cardiac electrophysiology procedures has increased significantly during the past 3 decades. Anesthesia requirements of these procedures can differ on the basis of patient- and procedure-specific factors. This manuscript outlines various anesthesia strategies for cardiac implantable electronic devices and electrophysiology procedures, including preprocedural, procedural, and postprocedural management. A team-based approach with collaboration between cardiac electrophysiologists and anesthesiologists is required with careful preprocedural and intraprocedural planning. Given the recent advances in electrophysiology, there is a need for specialized cardiac electrophysiology anesthesia care to improve the efficacy and safety of the procedures., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Left atrial appendage occlusion (LAAO) has become an important therapeutic target for stroke prevention in patients with nonvalvular atrial fibrillation. Over the past 2 decades, several advancements in LAAO devices (percutaneous and surgical) have been made for stroke prevention and arrhythmia therapy. However, there are several unanswered questions regarding optimal patient selection, the preferred LAAO approach and device, the management of periprocedural and postprocedural complications, including pericardial effusion, device-related thrombus, and device leaks. This review focuses on fundamental foundational concepts in various aspects of the left atrial appendage and management strategies as they relate to current clinical needs., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2025 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Cardiac arrhythmias are commonly noted in patients during infections with and recovery from COVID-19. Arrhythmic manifestations span the spectrum of innocuous and benign to life-threatening and deadly. Various pathophysiological mechanisms have been proposed. Debate continues on the impact of incident and exacerbated arrhythmias on the acute and chronic (recovery) phase of the illness. COVID-19 and COVID-19 vaccine-associated myocardial inflammation and autonomic disruption remain concerns. As the pandemic has transformed to an endemic, with discovery of new SARS-CoV-2 variants, updated vaccines, and potent antiviral drugs, vigilance for COVID-19-associated arrhythmic and dysautonomic manifestations remains. The objective of this American Heart Association scientific statement is to review the available evidence on the epidemiology, pathophysiology, clinical presentation, and management of cardiac arrhythmias and autonomic dysfunction in patients infected with and recovering from COVID-19 and to provide evidence-based guidance. The writing committee's consensus on implications for clinical practice, gaps in knowledge, and directions for future research are highlighted.

The rapid growth in consumer-facing mobile and sensor technologies has created tremendous opportunities for patient-driven personalized health management. The diagnosis and management of cardiac arrhythmias are particularly well suited to benefit from these easily accessible consumer health technologies. In particular, smartphone-based and wrist-worn wearable electrocardiogram (ECG) and photoplethysmography (PPG) technology can facilitate relatively inexpensive, long-term rhythm monitoring. Here we review the practical utility of the currently available and emerging mobile health technologies relevant to cardiac arrhythmia care. We discuss the applications of these tools, which vary with respect to diagnostic performance, target populations, and indications. We also highlight that requirements for successful integration into clinical practice require adaptations to regulatory approval, data management, electronic medical record integration, quality oversight, and efforts to minimize the additional burden to health care professionals., (© 2024. The Author(s).)

Competing Interests: Disclosures Dr Baykaner reports consulting/advisory board fees from Medtronic, Biotronik, and PaceMate. Dr Russo reports research grants from Boston Scientific and Kestra; consulting from Abbott, Boston Scientific, Medtronic, and PaceMate; and honoraria from Biotronik. Dr Freeman reports consulting/advisory board fees from Boston Scientific, Medtronic, Janssen Pharmaceuticals, Biosense Webster, and PaceMate and equity from PaceMate. Dr Gopinathannair reports that he has received consulting fees or honoraria from Abbott Medical, Boston Scientific, and Zoll Medical; and having served on the advisory board of PaceMate and AltaThera. Dr Deering reports that Piedmont Healthcare receives on his behalf research grants from Abbott, Biotronik, Biosense Webster, Medtronic, and Milestone; that he has consulted for CVRx, PaceMate, Preventice, and Sanofi while serving as a member of an Adjudication Committee for Abbott; that the University of Adelaide receives on his behalf lecture and/or consulting fees from Medtronic, Abbott Medical, Boston Scientific, CathRx, and PaceMate; and that the University of Adelaide receives on his behalf research funding from Medtronic, Abbott Medical, Boston Scientific, and Becton Dickenson. The remaining authors have nothing to disclose.

Introduction: Hemostasis following large-bore femoral vein access remains a challenge. Manual compression has been the standard of care but requires bedside staff, prolonged bed rest, and longer length of stay. The LockeT is an external compression device that attempts to address these issues while achieving venous hemostasis., Objectives: We evaluate postprocedural hemostasis and vascular closure outcomes after using LockeT following cardiac electrophysiologic procedures., Methods: We performed a single-center, observational study of patients who underwent vascular closure for electrophysiology procedures using LockeT. Postprocedural outcomes were subsequently analyzed., Results: We studied 102 patients (N) for whom LockeT was used to close 182 separate vascular access sites (n). Common procedures were atrial fibrillation ablation (56.9%, N = 58) and left atrial appendage occlusion (28.4%, N = 29). Most often, 8-Fr [48.3% (n = 126)], 11-Fr [27.2% (n = 71)], and 8.5-Fr [16.9% (n = 44)] sheaths were used, with an average procedure time of 82.1 ± 29.4 min. Hemostasis was achieved in 97.8% (n = 187) of all LockeT cases. Time to ambulation and discharge were 3.93 ± 1.10 h and 8.1 ± 4.4 h, respectively. No major complications were noted. Postprocedurally, 52% (N = 53) of patients were discharged on the same day. There were no differences in hemostasis (p = .859) or ambulation times (p = .202) between procedure types., Conclusion: The LockeT can effectively close venous access sites with no major complications., (© 2024 The Author(s). Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.)

Introduction: Management of patients with long-standing persistent atrial fibrillation (LSPAF) presents a clinical challenge. Hybrid convergent ablation has been shown to have superior efficacy compared to endocardial-only ablation. However, data on concomitant left atrial appendage (LAA) management along with hybrid ablation is sparse., Methods: We aimed to evaluate the effectiveness of concomitant hybrid convergent ablation and LAA clipping in patients with LSPAF. We conducted a retrospective analysis of all patients with LSPAF who underwent hybrid surgical ablation with LAA clipping at our institution. The primary endpoint was a recurrence of atrial arrhythmias at 12 months. Further, the durability of surgical left atrial posterior wall ablation was examined during the endocardial catheter ablation using standing electrophysiological criteria., Results: A total of 79 patients were included. Mean age was 63.5 ± 9.6 years, and 71% were males. LAA clipping was performed in 99% of patients. The mean time between the surgical and endocardial stages of the procedure was 2.6 ± 1.7 months. Persistent posterior wall activity was observed in 34.2% (n = 27/79) patients during the endocardial phase of the procedure. Cardiac implantable electronic device was used in 74% of patients for monitoring of recurrence of atrial fibrillation (AF). The primary effectiveness of AF freedom at 12 months was 73.8% (45/61). Over a 12-month follow-up period, 11.4% (9/79) of patients required repeat catheter ablation, of which 88.9% (8/9) had evidence of persistent posterior wall activity., Conclusion: Concomitant hybrid convergent ablation and LAA exclusion with an atrial clip provides reasonable long-term AF-free survival in patients with LSPAF. Persistent posterior wall activity is seen commonly in patients presenting with recurrent AF following hybrid convergent AF ablation., (© 2024 Wiley Periodicals LLC.)

Background: The use of cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs) significantly improve the chances of survival after out-of-hospital cardiac arrest. Subsequently, state laws mandate training in CPR and AED use for high school graduation. However, training and its impact vary and must be better understood., Objective: We assessed the current CPR training mandates and their impact., Methods: We performed a nationwide, cross-sectional, survey-based observational study of high schoolers in 9th to 12th grades in all 50 states from 2020 to 2022 (NCT04493970), assessing basic demographics, attitudes, knowledge and skills, and willingness to learn CPR and AED., Results: We had an 8% response rate, resulting in 2395 high school students surveyed. The mean age of respondents was 16.8 ± 0.7 years, with 52.5% female students. Of these, 86% underwent some form of training, and 25.1% had CPR training in the last year. Only 58.7% knew how to use an AED. Notably, 26.9% had previously witnessed CPR, and almost all (94%) realized the importance of learning CPR. Most respondents also believed recurrent and longitudinal would be beneficial., Conclusion: Surprisingly, only a small cohort of students undergo CPR training even when it is mandatory. The quality of this training appears to be inadequate to impart appropriate confidence and knowledge levels. This suggests a need for a significant overhaul of CPR training mandates across the United States., Competing Interests: Disclosures Dr Garg has received fees from Biosense Webster, Zoll, Kestra, and Biotronik. Dr Kabra has received fees from Volta Medical. Dr Pothineni has received fees from Medtronic and Biosense Webster; Dr Dhanunjaya Lakkireddy has received fees from Abbott Vascular, Biotronik, BioSense Webster, Medtronic, Boston Scientific, Atricure, Acutus, and Northeast Scientific. The other authors have no conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)

Background: Over 100,000 Abbott Riata ® were implanted in the United States before they were recalled in 2010. There are still a significant number of Abbott Riata ® leads in use, and it is unclear how these leads should be managed at the time of generator change or lead malfunction. Although data comparing both Sprint Fidelis ® and Abbott Riata ® leads in this setting is available, there are no multicenter comparative studies of outcomes for various lead management strategies, including lead extraction (LE), lead abandonment/revision (LA), and generator change (GC) only at the time of device at elective replacement interval (ERI) for Abbott Riata ® leads., Methods: A retrospective, multicenter study was undertaken to compare short-term outcomes (major complications-MC, death, extended or re-hospitalizations within 60 days-RH, lead malfunction-LM) and total outcomes (short-term outcomes & lead malfunction during follow-up) of patients with Riata ® leads undergoing LE, LA, or GC., Results: 152 patients (65 ± 13 years, 68% male) were followed for a mean 33 ± 30 months following intervention. Out of 166 procedures, 13 patients underwent LE, 16 patients underwent LA, and 137 patients underwent GC. There was 1 major complication in each group, yielding an event rate of 7.7% for LE, 6.3% for LA, and 0.7% for GC cohorts. There were significantly more short-term and total adverse outcomes in the group of patients getting LE and LA versus GC only (38.5% & 31.3% vs 7.3%, P < 0.001). Total Riata ® lead dwell time follow-up was 17,067 months. A total of 3 Riata ® lead malfunctions were noted during long-term follow-up. Inappropriate shocks were similar between LE 7.7% (1/13), LA 6.3% (1/16). and GC 11.0% (4/136); P = 0.57., Conclusions: There were more short-term and total adverse outcomes in more invasive management strategies (LE and LA) versus GC alone. The failure rate of Riata ® leads was substantially lower compared to previous reports. Therefore, we recommend only performing battery exchange when a device with an active Riata ® lead is at ERI, unless there is malfunction of the Riata ® lead noted on testing., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Real-world data have suggested inconsistent adherence to oral anticoagulation for thromboembolic event (TE) prevention in patients with Non valvular atrial fibrillation (NVAF), yet it remains unclear if event risk is elevated during gaps of non-adherence., Objective: To compare difference in outcomes between direct oral anticoagulant (DOAC) and warfarin based on adherence to the therapy in patients with NVAF., Methods: Using the MarketScan claims data, patients receiving prescription of warfarin or a DOAC for NVAF from January 2015 to June 2016 were included. Outcomes included hospitalization for TE (ischemic stroke or systemic embolism), hemorrhagic stroke, stroke of any kind, and major bleeding. Event rates were reported for warfarin and DOACs at a higher-adherence proportion of days covered (PDC > 80%) and lower-adherence (PDC 40-80%)., Results: The cohort included 83,168 patients prescribed warfarin (51% [n = 42,639]) or DOAC (49% [n = 40,529]). Lower adherence occurred in 36% (n = 15,330) of patients prescribed warfarin and 26% (n = 10,956) prescribed DOAC. As compared to higher-adherence warfarin after multivariable adjustment, the risk of TE was highest in lower-adherence DOAC (HR 1.26; 95% CI, 1.14-1.33), and lowest in higher-adherence DOAC (HR, 0.93; 95% CI, 0.88-0.99). There was a significantly higher risk of hemorrhagic stroke and stroke of any kind in the lower-adherence groups. Major bleeding was more common with lower-adherence DOAC (HR, 1.43, 95% CI, 1.35-1.52) and lower-adherence warfarin (HR, 1.32, 95% CI, 1.26-1.39)., Conclusions: In this large real-world study, low adherence DOAC was associated with higher risk of TE events as compared to high and low adherence warfarin., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Frailty is associated with significant morbidity and mortality and may have clinical implications in an advanced age population with atrial fibrillation undergoing left atrial appendage occlusion (LAAO). We sought to develop a novel frailty scale to predict worse outcomes in patients undergoing LAAO., Methods: Patients in the NCDR LAAO Registry between 2016 and 2021 receiving percutaneous LAAO devices were categorized as non-frail (0 points), pre-frail (1-3 points), or frail (4-5 points) based on a 5-point scale representing multiple domains of frailty: hemoglobin <13.0 g/dL in male, <12.0 g/dL in female; creatinine ≥1.2 mg/dL; albumin <3.5 g/dL; body mass index <20 kg/m2; and increased risk of falls., Results: Of 57,728 patients, 44,360 (76.8%) were pre-frail and 7693 (13.3%) were frail. Compared to non-frail, pre-frail and frail patients were older, had a higher burden of co-morbidities, and more disability based on the Modified Rankin Scale. Compared to non-frail patients after adjustment, frail patients were at higher risk of in-hospital major complication (OR 1.29, 95% 1.02-1.62, p = 0.01), any complication (OR 1.29, 95% CI 1.09-1.52, p = 0.0005), and death (OR 5.79, 95% CI 1.75-19.17, p = 0.001), while no difference was observed in pre-frail patients. At 45-day follow-up, there was no difference in the risk of complications in frail patients as compared to non-frail, although mortality was significantly higher (OR 3.01, 95% CI 1.97-4.85, p < 0.0001)., Conclusion: A simple and practical frailty scale accurately predicts adverse events in patients undergoing LAAO. The 13% of patients considered frail were at significantly higher risk of in-hospital adverse events and 45-day mortality., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Atrial fibrillation (AF) is the most common arrhythmia reported worldwide. There is significant heterogeneity in AF care pathways for a patient seen in the emergency room, impacting access to guideline-driven therapies., Objectives: The purpose of this study was to compare the difference in AF outcomes between those treated with an organized treatment pathway vs routine-care approach., Methods: The emergency room to electrophysiology service study (ER2EP) is a multicenter, prospective observational registry (NCT04476524) enrolling patients with AF from sites where a pathway for management of AF was put in place compared to sites where a pathway was not in place within the same health system and the same physicians providing services at all sites. Multivariable regression modeling was performed to identify predictors of clinical outcomes. Beta coefficient or odds ratio was reported as appropriate., Results: A total of 500 patients (ER2EP group, n = 250; control group, n = 250) were included in the study. The mean age was 73.4 ± 12.9 years, and 52.2% were males. There was a statistically significant difference in primary endpoint [time to ablation (56 ± 50.9 days vs 183.3 ± 109.5 days; P  < 0.001), time to anticoagulation initiation (2.1 ± 1.6 days vs 19.7 ± 35 days, P  < 0.001), antiarrhythmic drug initiation (4.8 ± 7.1 days vs 24.7 ± 44.4 days, P  < 0.001) compared to the control group, respectively. As such, this resulted in reduced length of stay in the ER2EP group compared to the control group (2.4 ± 1.4 days vs 3.23 ± 2.5 days, P  = 0.002)., Conclusions: This study provides evidence that having an organized pathway from the emergency department for AF patients involving electrophysiology services can improve early access to definitive therapies and clinical outcomes., Competing Interests: This study was supported by an unrestricted research grant from 10.13039/100007497Biosense Webster Inc and sponsored by the Kansas City Heart Rhythm Institute. Dr Lakkireddy is on the Speakers Bureau of Boston Scientific, Biosense Webster, Inc, and Janssen Pharmaceuticals; and has received honoraria/speaking/consulting fees from Abbott, Acutus, AtriCure Inc, Medtronic Inc, Philips, Biotronik, and Cardiovia. Dr Garg has received honoraria/speaking/consulting fees from Biosense Webster and Medtronic. Dr Gopinathannair has received honoraria/speaking/consulting fees from Sanofi, Abbott, Boston Scientific, Biosense Webster, Inc, Zoll Medical Corporation, Pfizer, Inc, and the Academy for Continued Healthcare Learning. Dr DiBiase has received honoraria/speaking/consulting fees from Baylis Medical Company, Biosense Webster, Inc, Abbott, Boston Scientific, Medtronic, Biotronik, Rhythm Management Group Corp, and Zoll Medical Corporation. Dr Al-Ahmad has received honoraria/speaking/consulting fees from Biosense Webster, Inc, Medtronic, Boston Scientific, Abbott, Mediasphere Medical, Medtelligence, and Biosig Technologies. Dr Natale has received honoraria/speaking/consulting fees from Medtronic, Biosense Webster, Inc, Boston Scientific, Abbott, Baylis Medical Company, and Biotronik. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Background: Cardioneuroablation has been emerging as a potential treatment alternative in appropriately selected patients with cardioinhibitory vasovagal syncope (VVS) and functional AV block (AVB). However the majority of available evidence has been derived from retrospective cohort studies performed by experienced operators., Methods: The Cardioneuroablation for the Management of Patients with Recurrent Vasovagal Syncope and Symptomatic Bradyarrhythmias (CNA-FWRD) Registry is a multicenter prospective registry with cross-over design evaluating acute and long-term outcomes of VVS and AVB patients treated by conservative therapy and CNA., Results: The study is a prospective observational registry with cross-over design for analysis of outcomes between a control group (i.e., behavioral and medical therapy only) and intervention group (Cardioneuroablation). Primary and secondary outcomes will only be assessed after enrollment in the registry. The follow-up period will be 3 years after enrollment., Conclusions: There remains a lack of prospective multicentered data for long-term outcomes comparing conservative therapy to radiofrequency CNA procedures particularly for key outcomes including recurrence of syncope, AV block, durable impact of disruption of the autonomic nervous system, and long-term complications after CNA. The CNA-FWRD registry has the potential to help fill this information gap., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Continuous flow left ventricular assist devices (CF-LVADs) have been shown to reduce mortality and morbidity in patients with advanced heart failure with reduced ejection fraction. However, ventricular arrhythmias (VA) are common, are mostly secondary to underlying myocardial scar, and have a higher incidence in patients with pre-LVAD VA. Sustained VA is well tolerated in the LVAD patient but can result in implantable defibrillator (ICD) shocks, right ventricular failure, hospitalizations, and reduced quality of life. There is limited data regarding best practices for the medical management of VA as well as the role for procedural interventions in patients with uncontrolled VA and/or ICD shocks. Vast majority of CF-LVAD patients have a preexisting cardiovascular implantable electronic device (CIED) and ICD and/or cardiac resynchronization therapies are continued in many. Several questions, however, remain regarding the efficacy of ICD and CRT following CF-LVAD. Moreover, optimal CIED programming after CF-LVAD implantation. Therefore, the primary objective of this review article is to provide the most up-to-date evidence and to provide guidance on the clinical significance, pathogenesis, predictors, and management strategies for VA and ICD therapies in the CF-LVAD population. We also discuss knowledge gaps as well as areas for future research., (© 2023 Wiley Periodicals LLC.)

Aim: The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation., Methods: A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate., Structure: Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Atrial fibrillation (AF) and heart failure are common overlapping cardiovascular disorders. Despite important therapeutic advances over the past several decades, controversy persists about whether a rate control or rhythm control approach constitutes the best option in this population. There is also considerable debate about whether antiarrhythmic drug therapy or ablation is the best approach when rhythm control is pursued.  A brief historical examination of the literature addressing this issue will be performed. An analysis of several important clinical outcomes observed in the prospective, randomized studies, which have compared AF ablation to non-ablation treatment options, will be discussed. This review will conclude with recommendations to guide clinicians on the status of AF ablation as a treatment option when considering management options in heart failure patients with atrial fibrillation., (© 2023 Wiley Periodicals LLC.)

Background: Bilateral cardiac sympathetic denervation (BCSD) for refractory life-threatening ventricular arrhythmias is a neuromodulatory intervention targeting sympathetically driven focal or re-entrant ventricular arrhythmias., Objectives: This study sought to provide a more complete and successful option for intervention in patients in whom premature ventricular contraction (PVC) ablation is not feasible or has been unsuccessful., Methods: A total of 43 patients with >5% PVC burden and concomitant nonischemic cardiomyopathy (NICM) who previously failed medical and ablation therapies were referred for BCSD. All patients underwent bilateral video-assisted thoracoscopic surgical approach with T1-T4 sympathectomy. Primary effectiveness endpoints were postprocedural PVC burden resolution, improvement in left ventricular ejection fraction (LVEF), and cessation of antiarrhythmic drugs (AADs). Safety endpoints included peri- and postprocedural complications. Outcomes were assessed over a 1-year follow-up period., Results: Among the 43 patients who underwent BCSD, the mean age was 52.3 ± 14.7 years, 69.8% of whom were male patients. Presenting mean LVEF was 38.7% ± 7.8%, and PVC burden was 23.7% ± 9.9%. There were significant reductions in PVC burden postprocedurally (1.3% ± 1.1% post-BCSD, compared with 23.7% ± 9.9% pre-BCSD, P < 0.001) and improvements in LVEF (46.3% ± 9.5% post-BCSD, compared with 38.7% ± 7.8% pre-BCSD, P < 0.001). The rate of ICD therapies decreased from 81.4% (n = 35) to 11.6% (n = 5) (P < 0.001), leading to a significant reduction in use of AADs (100.0% to 11.6%, P < 0.001) and improvement in mean NYHA functional class (2.5 ± 0.5 to 1.4 ± 0.2, P < 0.001). Major intraoperative complications were seen in 4.7% of patients (hemothorax and chylothorax). Of the patients, 81.4% (n = 35) experienced no mortality or major complications over a 1-year follow-up period, with the remaining still within their first year postprocedure., Conclusions: BCSD is effective for the management of refractory PVCs and ventricular tachycardia who have failed previous ablation therapy., Competing Interests: Funding Support and Author Disclosures Dr Lakkireddy has served as consultant for Abbott, Acutus, AltaThera, Boston Scientific, Biosense Webster, and Medtronic. Dr Pothineni has received speaking honoraria from Boston Scientific. Dr Gopinathannair has served as consultant and has received honoraria from Abbott Medical, and Sanofi; and has served on an advisory board for Pacemate. Dr Natale has served as consultants for Medtronic, Abbott, Biosense Webster, Boston Scientific, and Acutus. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Background: Hyperkalemia (HK) is a life-threatening condition that is frequently evaluated by electrocardiogram (ECG). ECG changes in severe HK (≥ 6.3 mEq/L) are not well-characterized. This study sought to compare and correlate ECG metrics in severe HK to baseline normokalemic ECGs and serum potassium., Methods: A retrospective analysis of 340 severe HK encounters with corresponding normokalemic ECGs was performed., Results: Various ECG metrics were analyzed. P wave amplitude in lead II, QRS duration, T wave slope, ratio of T wave amplitude: duration, and ratios of T wave: QRS amplitudes were significantly different between normokalemic and HK ECGs. P wave amplitude attenuation in lead II correlated better with serum potassium than in V 1 . T wave metrics that incorporated both T wave and QRS amplitudes correlated better than metrics utilizing T wave metrics alone., Conclusion: Multiple statistically significant and quantifiable differences among ECG metrics were observed between normokalemic and HK ECGs and correlated with increasing degrees of serum potassium and along the continuum of serum potassium. When incorporated into a logistic regression model, the ability to distinguish HK versus normokalemia on ECG improved significantly. These findings could be integrated into an ECG acquisition system that can more accurately identify severe HK., (Copyright © 2023. Published by Elsevier B.V.)

Background: Remote monitoring (RM) can facilitate early detection of subclinical and symptomatic atrial fibrillation (AF), providing an opportunity to evaluate the need for stroke prevention therapies. We aimed to characterize the burden of RM AF alerts and its impact on anticoagulation of patients with device-detected AF., Methods: Consecutive patients with a cardiac implantable electronic device, at least one AF episode, undergoing RM were included and assigned an estimated minimum CHA 2 DS 2 -VASc score based on age and device type. RM was provided via automated software system, providing rapid alert processing by device specialists and systematic, recurrent prompts for anticoagulation., Results: From 7651 individual, 389,188 AF episodes were identified, 3120 (40.8%) permanent pacemakers, 2260 (29.5%) implantable loop recorders (ILRs), 987 (12.9%) implantable cardioverter defibrillators, 968 (12.7%) cardiac resynchronization therapy (CRT) defibrillators, and 316 (4.1%) CRT pacemakers. ILRs transmitted 48.8% of all AF episodes. At twelve-months, 3404 (44.5%) AF < 6 min, 1367 (17.9%) 6 min-6 h, 1206 (15.8%) 6-24 h, and 1674 (21.9%) ≥ 24 h. A minimum CHA 2 DS 2 -VASc score of 2 was assigned to 1704 (63.1%) of the patients with an AF episode of ≥ 6 h, 531 (31.2%) who were not anticoagulated at 12-months, and 1031 (61.6%) patients with an AF episode duration of ≥ 24 h, 290 (28.1%) were not anticoagulated., Conclusions: Despite being intensively managed via RM software system incorporating cues for anticoagulation, a substantial proportion of patients with increased stroke risk remained unanticoagulated after a device-detected AF episode of significant duration. These data highlight the need for improved clinical response pathways and an integrated care approach to RM., Trial Registration: Australian New Zealand Clinical Trial Registry: ACTRN12620001232921., (© 2023. Crown.)

This article reviews the latest available data in regard to the diagnosis, management, and intervention of both central and peri-device leaks that arise after left atrial appendage closure (LAAC). The aim of this article is to have a better understanding of both addressing leaks arising after LAAC, and which interventions and closure methods are best served for each type of residual leak based on etiology, size, and operator experience., (© 2022 Wiley Periodicals LLC.)

Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified., (Copyright © 2023 The Heart Rhythm Society, the European Heart Rhythm Association, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: Left atrial appendage closure (LAAC) has shown to be non-inferior to oral anticoagulation (OAC) for non-valvular atrial fibrillation (AF). LAAC is now becoming a leading method for stroke prophylaxis in patients who have atrial fibrillation and are unable to tolerate OAC. There are currently two FDA-approved endocardial closure devices, namely, the Watchman FLX and Amplatzer Amulet., Recent Findings: Current data highlights that both devices offer similar efficacy and safety for LAAC. While the two devices differ in terms of intraprocedural complication rates, they offer similar short- to long-term outcomes in regard to peri-device leaks, device-related thrombosis, and mortality. With similar risk and safety profiles, both devices are indicated for patients who are unable to tolerate OAC. Newer clinical studies are directed to establish the efficacy of both devices as the primary method for stroke prevention in AF as an alternate to OAC., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: New and persistent left bundle branch block (NP-LBBB) following Transcatheter Aortic Valve Replacement (TAVR) is an ongoing concern with incidence ranging from as low as 4% to up to 65% (varying for different types of valves). Such patients are at risk of developing high-grade atrioventricular block (HAVB) warranting permanent pacemaker (PPM) implantation. However, currently, there are no consensus guidelines or large prospective studies to risk stratify these patients for safer discharge after TAVR., Objectives: To provide insight from a single center study on using modified electrophysiology (EP) study to risk stratify post-TAVR patients to outpatient monitoring for low-risk versus pacemaker implantation for high-risk patients., Methods and Results: Between June 2020 and March 2023, all patients who underwent a TAVR procedure (324 patients) at our institution were screened for development of NP-LBBB post-operatively. Out of 26 patients who developed NP-LBBB, after a pre-specified period of observation, 18 patients were deemed eligible for a modified EP study to assess His-Ventricular (HV) interval. 11 out of 18 patients (61.1%) had normal HV interval (HV < 55 ms). Three out of 18 patients (16.7%) had HV prolongation (55 ms < HV < 70 ms) without significant HV prolongation (defined as an increase in HV interval > 30%) with intra-procedural procainamide challenge. Four out of 18 patients (22.2%) had significant HV prolongation (HV > 70 ms) warranting PPM implantation based on a multidisciplinary approach and shared decision-making with the patients. Total of 50% of patients discharged with PPM (two out of four patients) were noted to be pacemaker dependent based on serial device interrogations. All patients who did not receive PPM were discharged with ambulatory monitoring with 30-day event monitor and did not develop HAVB on serial follow-up., Conclusion: Normal HV interval up to 55 ms on modified EP study after TAVR and development of NP-LBBB can be utilized as a threshold for risk stratification to facilitate safe discharge. The optimal upper limit of HV interval threshold remains unclear in determining appropriate candidacy for PPM., (© 2023 Wiley Periodicals LLC.)

Introduction: Insertable cardiac monitors (ICMs) are commonly used to diagnose cardiac arrhythmias. False detections in the latest ICM systems remain an issue, primarily due to inaccurate R-wave sensing. New discrimination algorithms were developed and tested to reduce false detections of atrial fibrillation (AF), pause, and tachycardia episodes in ICMs., Methods: Stored electrograms (EGMs) of AF, pause, and tachycardia episodes detected by Abbott Confirm Rx™ ICMs were extracted from the Merlin.net™ Patient Care Network, and manually adjudicated to establish independent training and testing datasets. New discrimination algorithms were developed to reject false episodes due to inaccurate R-wave sensing, P-wave identification, and R-R interval patterns. The performance of these new algorithms was quantified by false positive reduction (FPR) and true positive maintenance (TPM), relative to the existing algorithms., Results: The new AF detection algorithm was trained on 5911 EGMs from 744 devices, resulting in 66.9% FPR and 97.8% TPM. In the testing data set of 1354 EGMs from 119 devices, this algorithm achieved 45.8% FPR and 97.0% TPM. The new pause algorithm was trained on 7178 EGMs from 1490 devices, resulting in 70.9% FPR and 98.7% TPM. In the testing data set of 1442 EGMs from 340 devices, this algorithm achieved 74.4% FPR and 99.3% TPM. The new tachycardia algorithm was trained on 520 EGMs from 204 devices, resulting in 57.0% FPR and 96.6% TPM. In the testing data set of 459 EGMs from 237 devices, this algorithm achieved 57.9% FPR and 96.5% TPM., Conclusion: The new algorithms substantially reduced false AF, pause, and tachycardia episodes while maintaining the majority of true arrhythmia episodes detected by the Abbott ICM algorithms that exist today. Implementing these algorithms in the next-generation ICM systems may lead to improved detection accuracy, in-clinic efficiency, and device battery longevity., (© 2023 Wiley Periodicals LLC.)

Purpose of Review: In this review, we aim to delve into the existing literature, seeking to uncover the mechanisms, investigate the electrocardiographic changes, and examine the treatment methods of various cardiac arrhythmias that occur after administration of the COVID-19 vaccine., Recent Findings: A global survey has exposed an incidence of arrhythmia in 18.27% of hospitalized COVID-19 patients. Furthermore, any type of COVID-19 vaccine - be it mRNA, adenovirus vector, whole inactivated, or protein subunit - appears to instigate cardiac arrhythmias. Among the cardiac adverse events reported post-COVID-19 vaccination, myocarditis emerges as the most common and is thought to be a potential cause of bradyarrhythmia. When a patient post-COVID-19 vaccination presents a suspicion of cardiac involvement, clinicians should perform a comprehensive history and physical examination, measure electrolyte levels, conduct ECG, and carry out necessary imaging studies. In our extensive literature search, we uncovered various potential mechanisms that might lead to cardiac conduction abnormalities and autonomic dysfunction in patients who have received the COVID-19 vaccine. These mechanisms encompass direct viral invasion through molecular mimicry/spike (S) protein production, an escalated inflammatory response, hypoxia, myocardial cell death, and the eventual scar/fibrosis. They correspond to a range of conditions including atrial tachyarrhythmias, bradyarrhythmia, ventricular arrhythmias, sudden cardiac death, and the frequently occurring myocarditis. For treating these COVID-19 vaccination-induced arrhythmias, we should incorporate general treatment strategies, similar to those applied to arrhythmias from other causes., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Surgical left atrial appendage (LAA) occlusion with an AtriClip (AtriCure, West Chester, Ohio) is frequently performed for stroke prophylaxis in patients with atrial fibrillation (AF). We conducted a retrospective analysis of all patients with long-standing persistent AF who underwent hybrid convergent ablation and LAA clipping. Contrast-enhanced cardiac computed tomography was performed at 3 to 6 months after LAA clipping to assess the degree of complete closure and the residual LAA stump. A total of 78 patients (64 ± 10 years, 72% male) underwent LAA clipping as part of hybrid convergent AF ablation, from 2019 to 2020. Median size of AtriClip used was 45 mm. Mean LA size was 4.6 ± 1 cm. At 3-to-6 months follow-up computed tomography, 46.2% of patients (n = 36) had a residual stump proximal to the deployed LAA clip. Mean depth of residual stump was 3.95 ± 5.5 mm, with 19% of patients (n = 15) having a stump depth of ≥10 mm and 1 patient requiring more endocardial LAA closure owing to large stump depth. During 1-year follow-up, 3 patients developed stroke; device leak of 6 mm was noted in 1 patient; and none of the patients had a thrombus proximal to the clip. In conclusion, high incidence of residual LAA stump was observed with AtriClip. Larger studies with long-term follow-up are needed to better assess the thromboembolic implications of a residual stump after AtriClip placement., Competing Interests: Declaration of Competing Interest Dr. Pothenini reports speaking honorarium from Boston Scientific. Dr. Singh reports research grant—American Society of Nuclear Cardiology and Pfizer; Advisory Board—Pfizer; and speaker bureau—Pfizer. Dr. Lakkireddy reports being consultant to Bionsense Webster, Boston Scientific, Abbott, AtriCure, Alta Thera, Phillips, and Acutus. Dr. Gopinathannair reports consultancy/honoraria—Abbott Medical and Sanofi; and being on the advisory board of Pacemate. The remaining authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Aims: No prior study has been adequately powered to evaluate real-world safety outcomes in those receiving adjunctive ablation lesions beyond pulmonary vein isolation (PVI). We sought to evaluate characteristics and in-hospital complications among patients undergoing PVI with and without adjunctive lesions., Methods and Results: Patients in the National Cardiovascular Data Registry AFib Ablation Registry undergoing first-time atrial fibrillation (AF) ablation between 2016 and 2020 were identified and stratified into paroxysmal (PAF) and persistent AF, and separated into PVI only, PVI + cavotricuspid isthmus (CTI) ablation, and PVI + adjunctive (superior vena cava isolation, coronary sinus, vein of Marshall, atypical atrial flutter lines, other). Adjusted odds of adverse events were calculated using multivariable logistic regression. A total of 50 937 patients [PAF: 30 551 (60%), persistent AF: 20 386 (40%)] were included. Among those with PAF, there were no differences in the adjusted odds of complications between PVI + CTI or PVI + adjunctive when compared with PVI only. Among persistent AF, PVI + adjunctive was associated with a higher risk of any complication [3.0 vs. 4.5%, odds ratio (OR) 1.30, 95% confidence interval (CI) 1.07-1.58] and major complication (0.8 vs. 1.4%, OR 1.56, 95% CI 1.10-2.21), while no differences were observed in PVI + CTI compared with PVI only. Overall, there was high heterogeneity in adjunctive lesion type, and those receiving adjunctive lesions had a higher comorbidity burden., Conclusion: Additional CTI ablation was common without an increased risk of complications. Adjunctive lesions other than CTI are commonly performed in those with more comorbidities and were associated with an increased risk of complications in persistent AF, although the current analysis is limited by high heterogeneity in adjunctive lesion set type., Competing Interests: Conflict of interest: J.C.H. reports receiving honoraria from Medtronic, Abbott, Boston Scientific, Biotronik, Janssen Pharmaceuticals, Bristol-Myers Squibb, Pfizer, Sanofi, Zoll Medical, iRhythm, Acutus Medical, Galvanize Therapeutics, and Biosense Webster, research grants from Biotronik and Biosense Webster, and has equity interest in Vektor Medical. J.V.F. has received salary support from the American College of Cardiology NCDR and the National Heart, Lung, and Blood Institute; and has received consulting/Advisory Board fees (modest) from Boston Scientific, Medtronic, Janssen Pharmaceuticals, and Biosense Webster; and has equity interest in PaceMate. J.P.C. has an institutional contract with the American College of Cardiology for his role as Senior Scientific Advisor of the NCDR; has received salary support from the American College of Cardiology and Centers for Medicaid and Medicare Services; and has equity in Medtronic. D.L. reports receiving honoraria from Abiomed, Biosense Webster, Boston Scientific, Biotronik, Janssen, and Abbott Medical. R.G. reports receiving Honoria from Abbott Medical, Boston Scientific, Pfizer, Zoll Medical; Advisory board: Pacemate (no compensation). G.K.F. as Director of the UCSD EP Fellowship Training Program reports fellow stipend support from Biosense Webster, Inc., Biotronik, Inc., Boston Scientific, Inc., Abbott Medical, Inc., and Medtronic, Inc., is a consultant to Acutus Medical, Inc., and Vektor Medical, Inc., and has equity interest in Vektor Medical, Inc. All remaining authors have declared no conflicts of interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Remote monitoring (RM) has been accepted as a standard of care for follow-up of patients with cardiac implantable electronic devices (CIEDs). However, the resulting data deluge poses major challenge to device clinics., Objective: This study aimed to quantify the data deluge from CIED and stratify these data based on clinical relevance., Methods: The study included patients from 67 device clinics across the United States being remotely monitored by Octagos Health. The CIEDs included implantable loop recorders, pacemakers, implantable cardioverter-defibrillators, cardiac resynchronization therapy defibrillators, and cardiac resynchronization therapy pacemakers. Transmissions were either dismissed before reaching the clinical practice if they were repetitive or redundant or were forwarded if they were either clinically relevant or actionable transmission (alert). The alerts were further classified as level 1, 2, or 3 based on clinical urgency., Results: A total of 32,721 patients with CIEDs were included. There were 14,465 (44.2%) patients with pacemakers, 8381 (25.6%) with implantable loop recorders, 5351 (16.4%) with implantable cardioverter-defibrillators, 3531 (10.8%) with cardiac resynchronization therapy defibrillators, and 993 (3%) with cardiac resynchronization therapy pacemakers. Over a period of 2 years of RM, 384,796 transmissions were received. Of these, 220,049 (57%) transmissions were dismissed, as they were either redundant or repetitive. Only 164,747 (43%) transmissions were transmitted to the clinicians, of which only 13% (n = 50,440) had clinical alerts, while 30.6% (n = 114,307) were routine transmissions., Conclusion: Our study shows that data deluge from RM of CIEDs can be streamlined by utilization of appropriate screening strategies that will enhance efficiency of device clinics and provide better patient care., (© 2023 Heart Rhythm Society. Published by Elsevier Inc.)