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General anesthesia (GA) is the standard sedation approach for subcutaneous cardioverter-defibrillator (S-ICD) implantation. Nonetheless, GA is expensive and can be associated with adverse events. Tumescent local anesthesia (TLA) has been shown to reduce in-room and procedural times, and to decrease post-procedural pain, all of which could result in a reduction in procedure-related costs.To compare the cost-effectiveness of GA and TLA in patients undergoing S-ICD implantation.Prospective, controlled study of patients who underwent S-ICD implantation between 2019 and 2022. Patients were allocated to either TLA or GA group. We performed a cost analysis for each intervention. As an effectiveness measure, the 0-10 point pain numerical rating scale at 1-, 12- and 24-hours post-implantation was analyzed and compared between groups. A score of 0 was considered no pain; 1 to 5: mild pain; 6 to 7: moderate pain and 8 to 10: severe pain. Cost-effectiveness was calculated using incremental cost-effectiveness ratios.70 patients underwent successful S-ICD implantation. The total cost of the electrophysiology laboratory was higher in the GA group compared to the TLA group (median±IQR of $55,824±29,411 vs. $37,222±24,293, p0.001), with a net savings of $20,821 when compared with GA for each S-ICD implantation. There was a significant decrease in post-procedural pain scores within the TLA group when compared to the GA group (repeated measures ANOVA p=0.009, median±IQR of 0±3 vs. 0±5 at 1hr, p=0.058; 3±4 vs. 6±8 at 12hrs, p=0.030; 0±4 vs. 2±6 at 24hrs, p=0.040).TLA is a more cost-effective alternative to GA for S-ICD implantation, with both direct and indirect cost reductions. Importantly, these reduced costs are associated with reduced post-procedural pain.

Electrical isolation of pulmonary veins (PVI) is a cornerstone for Atrial Fibrillation (AF) ablation. The overall effect of AF ablation, and especially lesions beyond PVI, on left atrial (LA) function is currently poorly understood.Our aim was to determine if LA function is different in patients after extensive LA ablation compared to PVI only. We performed non-inferiority analysis of LA function after PVI with additional non-pulmonary vein ablation lesions in LA (PVI+) and PVI alone.We studied 68 patients consecutive patients who underwent AF ablation and who had complete echocardiograms (TTE) within 12 months prior to AF ablation and 1-12 months after the procedure. Patients were stratified into 2 groups: PVI only and PVI+. Primary outcome was change in LA reservoir strain (LASr). Non-inferiority margin was defined at 6%.The PVI only group had a higher proportion of patients with paroxysmal AF (70% vs 30%). The PVI + group was observed to have a slightly higher increase in LASr compared to PVI alone (5.0%vs 4.3%, p0.01 for non-inferiority). LASr non-inferiority was confirmed when adjusted for age, sex, CAD, HLD, AF type, rhythm at pre-procedure TTE in a multivariable linear regression model, 90% CI (-5.46; 2.04), p0.01.LA functional improvement evaluated by LASr was non-inferior after PVI with additional LA ablation lesions compared to PVI alone. These findings were confirmed when adjusted for confounding clinical variables, suggesting that more extensive ablation does not negatively affect LA function. This article is protected by copyright. All rights reserved.

Aims The aim of this study is to provide guidance for the clinical interpretation of electrocardiograms (ECGs) in prone position and to establish the electroanatomic explanations for the possible differences to supine position ECGs that may be observed. Additionally, to determine if prone back ECG can be used as an alternative to standard ECG in patients who may benefit from prone position. Methods and results The ECG in supine (standard ECG), prone back (precordial leads placed on the patient’s back), and prone anterior position (precordial leads placed in the standard position with the subjects in prone position) were prospectively examined on 85 subjects. Comparisons of ECG parameters between these positions were performed. Computed tomography (CT) scans were performed in both positions to determine possible electroanatomic aetiologies for prone-associated ECG changes. There were significant differences in QRS amplitude in Leads V1–V5 between supine and prone positions. Q waves were more frequently observed in prone back position vs. supine position (V1: 74.1 vs. 10.6%, P < 0.0001; V2: 23.5 vs. 0%, P < 0.0001, respectively). Flat and inverted T waves were more common in prone back leads (V1: 98 vs. 66%, P < 0.0001; V2: 96 vs. 8%, P < 0.0001; V3: 45 vs. 7%, P < 0.0001). The 3D-CT reconstructions measurements corroborated the significant inverse correlation between QRS amplitude and the distance from the centre of the heart to the estimated lead positions. Conclusion In prone back position ECG, low QRS amplitude should not be misinterpreted as low voltage conditions, neither should Q waves and abnormal T waves are considered anteroseptal myocardial infarction. These changes can be explained by an increased impedance (due to interposing lung tissue) and by the increased distance between the electrodes to the centre of the heart.

Catheter ablation (CA) has become the mainstay therapy for the maintenance of sinus rhythm in patients with atrial fibrillation (AF), with pulmonary vein isolation (PVI) the most frequently used treatment strategy. Although several energy sources have been tested (including radiofrequency, cryothermal and laser), these are not devoid of safety issues and in many instances effectiveness is dependent on operator experience. Pulsed field ablation (PFA) is a novel energy source by which high-voltage electric pulses are used to create pores in the cellular membrane (i.e., electroporation), leading to cellular death. The amount of energy required to produce irreversible electroporation is highly tissue dependent. In consequence, a tailored protocol in which specific targeting of the atrial myocardium is achieved while sparing adjacent tissues is theoretically feasible, increasing the safety of the procedure. While large scale clinical trials are lacking, current clinical evidence has demonstrated significant efficacy in achieving durable PVI without ablation related adverse events.

Aims Prevalent atrial fibrillation (AF) is associated with excess cardiovascular (CV) death (D) and hospitalizations (H) in heart failure (HF) with preserved ejection fraction (pEF). We evaluated if it had an independent role in excess CVD in HFpEF and studied its impact on cause-specific mortality and HF morbidity. Methods and results We used propensity score–matched (PSM) cohorts from the TOPCAT Americas trial to account for confounding by other co-morbidities. Two prevalent AF presentations at study entry were compared: (i) subjects with Any AF event by history or on electrocardiogram (ECG) with PSM subjects without an AF event and (ii) subjects in AF on ECG with PSM subjects in sinus rhythm. We analyzed cause-specific modes of death and HF morbidity during a mean follow-up period of 2.9 years. A total of 584 subjects with Any AF event and 418 subjects in AF on ECG were matched. Any AF was associated with increased CVH [hazard ratio (HR) 1.33, 95% confidence interval (CI) 1.11–1.61, P = 0.003], HFH (HR 1.44, 95% CI 1.12–1.86, P = 0.004), pump failure death (PFD) (HR 1.95, 95% CI 1.05–3.62, P = 0.035), and HF progression from New York Heart Association (NYHA) classes I/II to III/IV (HR 1.30, 95% CI 1.04–1.62, P = 0.02). Atrial fibrillation on ECG was associated with increased risk of CVD (HR 1.46, 95% CI 1.02–2.09, P = 0.039), PFD (HR 2.21, 95% CI 1.11–4.40, P = 0.024), and CVH and HFH (HR 1.37, 95% CI 1.09–1.72, P = 0.006 and HR 1.65, 95% CI 1.22–2.23, P = 0.001, respectively). Atrial fibrillation was not associated with risk of sudden death. Both Any AF and AF on ECG cohorts were associated with PFD in NYHA class III/IV HF. Conclusion Prevalent AF can be an independent risk factor for adverse CV outcomes by its selective association with worsening HF, HFH, and PFD in HFpEF. Prevalent AF was not associated with excess sudden death risk in HFpEF. Atrial fibrillation was also associated with HF progression in early symptomatic HFpEF and PFD in advanced HFpEF. Trial registration TOPCAT trial is registered at www.clinicaltrials.gov:identifier NCT00094302.

In this study, the authors investigated the ablation success of scar homogenization with combined (epicardial + endocardial) vs endocardial-only approach for ventricular tachycardia (VT) in patients with ischemic cardiomyopathy (ICM) at 5 years of follow-up.Best ablation approach to achieve long-term success rate in VT patients with ICM is not known yet.Consecutive ICM patients undergoing VT ablation at our center were classified into group 1: endocardial + epicardial scar homogenization and group 2: endocardial scar homogenization. Patients with previous open heart surgery were excluded. Epicardial ablation was performed despite being noninducible after endocardial ablation in all group 1 patients. All patients underwent bipolar substrate mapping with standard scar settings defined as normal tissue1.5 mV and severe scar 0.5 mV. Noninducibility of monomorphic VT was the procedural endpoint in both groups. Patients were followed up every 4 months for 5 years with implantable device interrogations.A total of 361 patients (group 1: n = 70 and group 2: n = 291) were included in the study. At 5 years, 81.4% (n = 57/70) patients from group 1 and 66.3% (n = 193/291) from group 2 were arrhythmia-free (P = 0.01) Of those patients, 26 of 57 (45.6%) and 172 of 193 (89.1%) from group 1 and group 2 respectively were on anti-arrhythmic drugs (AAD) (log-rank P0.001). After adjusting for age, sex, and obstructive sleep apnea, endo-epicardial scar homogenization was associated with a significant reduction in arrhythmia-recurrence (HR: 0.48; 95% CI: 0.27-0.86; P = 0.02).In this series of patients with ICM and VT, epicardial substrate was detected in all group 1 patients despite being noninducible after endocardial ablation. Moreover, combined endo-epicardial scar homogenization was associated with a significantly higher success rate at 5 years of follow-up and a substantially lower need for antiarrhythmic drugs after the procedure compared with the endocardial ablation alone.

Background: We aimed to assess the prevalence of ischemic brain lesions detected by magnetic resonance imaging and their association with cognitive function 3 months after first-time ablation using continuous oral anticoagulation in patients with paroxysmal atrial fibrillation (AF). Methods: We performed a prespecified analysis of the AXAFA-AFNET 5 trial (Anticoagulation Using the Direct Factor Xa Inhibitor Apixaban During Atrial Fibrillation Catheter Ablation: Comparison to Vitamin K Antagonist Therapy), which randomized 674 patients with AF 1:1 to uninterrupted apixaban or vitamin K antagonist therapy before first-time ablation. Brain magnetic resonance imaging using fluid-attenuated inversion recovery and high-resolution diffusion-weighted imaging was obtained within 3 to 48 hours after AF ablation in all eligible patients enrolled in 25 study centers in Europe and the United States. Patients underwent cognitive assessment 3 to 6 weeks before ablation and 3 months after ablation using the Montreal Cognitive Assessment (MoCA). Results: In 84 (26.1%) of 321 patients with analyzable magnetic resonance imaging, high-resolution diffusion-weighted imaging detected at least 1 acute brain lesion, including 44 (27.2%) patients treated with apixaban and 40 (24.8%) patients treated with vitamin K antagonist ( P =0.675). Median MoCA score was similar in patients with or without acute brain lesions at 3 months after ablation (28 [interquartile range (IQR), 26–29] versus 28 [IQR, 26–29]; P =0.948). Cerebral chronic white matter damage (defined as Wahlund score ≥4 points) detected by fluid-attenuated inversion recovery was present in 130 (40.5%) patients and associated with lower median MoCA scores before ablation (27 [IQR, 24–28] versus 27 [IQR, 25–29]; P =0.026) and 3 months after ablation (27 [IQR, 25–29] versus 28 [IQR, 26–29]; P =0.011). This association was no longer significant when adjusted for age and sex. Age was associated with lower MoCA scores before ablation (relative risk, 1.02 per 10 years [95% CI, 1.01–1.03]) and 3 months after ablation (relative risk, 1.02 per 10 years [95% CI, 1.01–1.03]). Conclusions: Chronic white matter damage as well as acute ischemic lesions detected by brain magnetic resonance imaging were found frequently after first-time ablation for paroxysmal AF using uninterrupted oral anticoagulation. Acute ischemic brain lesions detected by high-resolution diffusion-weighted imaging were not associated with cognitive function at 3 months after ablation. Lower MoCA scores before and after ablation were associated only with older age, highlighting the safety of AF ablation on uninterrupted oral anticoagulation. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02227550.

Synopsis We review the current data on epidemiology, the clinical significance, the pathophysiologic mechanisms, and the treatment of VAs in the setting of COVID-19. VAs prevail in 0.15-8% of in hospitalized patients, but only sustained and rapid tachyarrhythmias are purportedly associated with a significant increase in mortality. Multiple factors can elicit VAs, which are ultimately deemed to be a marker of severe systemic disease rather than a distinct cardiac condition. Even though the electrophysiologist plays a determinant role in the secondary prevention of VAs, a multidisciplinary approach is indispensable for primary prophylaxis and acute management.

BACKGROUND: Medical treatment of inappropriate sinus tachycardia (IST) remains suboptimal. Radiofrequency sinus node (RF-SN) ablation has poor success and higher complication rates. OBJECTIVE: We aimed to compare clinical outcomes of the novel SN sparing hybrid ablation technique with those of RF-SN modification for IST management. METHODS: This is a multicenter prospective registry comparing the SN sparing hybrid ablation strategy with RF-SN modification. The hybrid procedure was performed using an RF bipolar clamp, isolating superior vena cava/inferior vena cava with the creation of a lateral line across the crista terminalis while sparing the SN region (identified by endocardial 3-dimensional mapping). RF-SN modification was performed by endocardial and/or epicardial mapping and ablation at the site of earliest atrial activation. RESULTS: Of the 100 patients (hybrid ablation group, n = 50; RF-SN group, n = 50), 82% were women, and the mean age was 22.8 years. Normal sinus rhythm and rate were restored in all patients in the hybrid group (vs 84% in the RF-SN group; P = .006). Hybrid ablation was associated with significantly better improvement in mean daily heart rate and peak 6-minute walk heart rate compared with RF-SN ablation. The RF-SN group had a significantly higher rate of redo procedures (100% vs 8%; P < .001), phrenic nerve injury (14% vs 0%; P = .012), lower acute pericarditis (48% vs 92%; P < .0001), permanent pacemaker implantation (50% vs 4%; P < .0001) than did the hybrid ablation group. CONCLUSION: The novel sinus node sparing hybrid ablation procedure appears to be more efficacious and safer in patients with symptomatic drug-resistant IST with long-term durability than RF-SN ablation.

AimsThis study aimed to examine the clinical benefits of targeted ablation of all Premature ventricular complex (PVC) morphologies vs. predominant PVC only.Methods and resultsA total of 171 consecutive patients with reduced left ventricular ejection fraction (LVEF) and ≥2 PVC morphology with high burden (>10%/day) undergoing their first ablation procedure were included in the analysis. At the initial procedure, prevalent PVC alone was ablated in the majority. However, at the redo, all PVC morphologies were targeted for ablation. : At the first procedure, 152 (89%) patients received ablation of the dominant PVC only. In the remaining 19 (11%) patients, all PVC morphologies were ablated. At two years, high PVC burden was detected in 89 (52%) patients. Repeat procedure was performed in 78 of 89, where all PVC morphologies were ablated. At 5 years after the repeat procedure, 71 (91%) had PVC burden of ConclusionIn this observational series, ablation of all PVC morphologies was associated with significantly lower PVC burden and improvement of LVEF at long-term follow-up, compared with ablation of the dominant morphology only.

Background: The inspIRE study (Study for Treatment of Paroxysmal Atrial Fibrillation [PAF] by Pulsed Field Ablation [PFA] System With Irreversible Electroporation [IRE]) evaluated safety and effectiveness of a fully integrated biphasic pulsed field ablation (PFA) system with a variable-loop circular catheter for the treatment of drug-refractory paroxysmal atrial fibrillation.Methods: Subjects underwent pulmonary vein (PV) isolation with the PFA system, using at least 12 applications per vein; adenosine/isoproterenol was administered to confirm entrance block. Wave I assessed initial safety, including for esophageal lesions, silent cerebral lesions, and PV stenosis. Wave II (pivotal phase) tested (1) primary safety, incidence of early-onset primary adverse events, and (2) primary effectiveness, confirmed PV isolation with freedom from documented atrial arrhythmia at 12 months. The study design specified an interim analysis to determine early success once 30 subjects reached the 12-month follow-up and all subjects reached 3-month follow-up.Results: Across 13 centers in Europe/Canada, 226 subjects were enrolled, met criteria for safety and effectiveness evaluations, and received PFA (Wave I, 40; Wave II, 186). Wave I demonstrated no esophageal thermal lesions or PV stenosis. Among 39 subjects with cerebral magnetic resonance imaging, silent cerebral lesions were detected in 4 of the first 6 subjects, after which workflow enhancements, including a 10-second pause between PFA applications, were implemented; subsequently, only 4 of 33 subjects had silent cerebral lesions. In the Wave II phase, no primary adverse events were reported. Upon declaring early success, 83 subjects reached 12-month follow-up. With 100% entrance block, PV isolation without acute reconnection was achieved in 97.1% of targeted veins. For Wave II, the primary effectiveness end point per Kaplan-Meier at the time of interim analysis was 70.9%; 12-month freedom from symptomatic atrial fibrillation/atrial flutter/atrial tachycardia recurrence and repeat ablation was 78.9% and 92.3%, respectively. Total procedure and transpired PFA times were 70.1 +/- 27.7 and 26.7 +/- 14.0 minutes, respectively.Conclusions: The inspIRE trial confirmed the safety and effectiveness of the novel mapping-integrated PFA system. The authors would like to express their deepest gratitude to all investigators, including coinvestigators and guest operating investigators. They wish to thank the following individuals for their support in trial design, execution, statistical analysis, medical writing, and additional value to developing the manuscript: Carmen Rousseeuw, Sarah Rabau, Liesbeth Vanderlinden, Lee Ming Boo, Christina Kaneko, Jaclyn Alcazar, Tara Gomez, Tiffany Tan, Melissa Mert, Guixia Huang, Xiaoxue Gu, Puneet Jatana, Rebecca Beals, and Dror Berman (all employees of Biosense Webster, Inc.). Michelle Hughes, Bsc, with Lumanity Communications Inc (Yardley, PA), provided medical writing and editorial support, in accordance with Good Publication Practice guidelines, which were funded by Biosense Webster, Inc, under direction of the authors.